HTML Preview Childcare Registration Form page number 1.
10.9.2.6 Child Care Registration Form
Rev. 04/12
Child Care Registration Form
Date child entered care
Date child left care
Child’s name Last First Middle
Name (Nickname) used
Birthdate
Street address City Zip code
Child’s parent/guardian name
home phone #
( ) -
cell phone#
( ) -
alternative phone #
( ) -
Street address City Zip code
Address where you can be reached while child is in care City Zip code
Child’s parent/guardian name
home phone #
( ) -
cell phone#
( ) -
alternative phone #
( ) -
Street address City Zip code
Address where you can be reached while child is in care City Zip code
Other than you, who else has permission to pick up your child?
Name
Address
Telephone number
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative: ( ) -
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative: ( ) -
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative: ( ) -
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative: ( ) -
In case of an emergency, I give permission for any of the following individuals to be contacted and my child may be
released to any of them.
Parent/Guardian signature:
Name
Address
Telephone number
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative: ( ) -
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative: ( ) -
Name:
Relationship:
Home: ( ) -
Cell: ( ) -
Alternative: ( ) -