Register

Child Information

First Name

Last Name

Sex

Date of Birth

Program

School

Schoool Phone #

School Address

Child Lives With

Living Type

Mother/Gaurdian

First Name

Last Name

Home Address

Postal Code

Work Address

Postal Code

Home Phone

Work Phone

Cell Phone

Father/Gaurdian

First Name

Last Name

Home Address

Postal Code

Work Address

Postal Code

Home Phone

Work Phone

Cell Phone

Emergency Contact (Other than parents)

First Name

Last Name

Relationship

Address

Postal Code

Home Phone

Cell Phone

Authorized to Pickup

Health Information

Health Care No.

Physician Name

Phone Number

Physician's Address

Child Immunized Up to Date

Allergies

Any Restrictions or Medical Concerns

Any Medication on Regular Basis

If Yes, Then Please Specify