Child Care Registration Release Form printable pdf download

Child Care Registration Release Form

MAC Kids

Child care registration/release form

Member?

YES

Member #_____________

Child #1 Name________________________________Sex: M / F

AGE___________

Child #2 Name________________________________Sex: M / F

AGE___________

Child #3 Name________________________________Sex: M / F

AGE___________

Address_________________________ City___________ State______ Zip__________

Parent Names____________________________________________________________

Phone #’s: Home___________________Work________________Cell_______________

Person(s) authorized to pick up child__________________________________________

In case of an emergency we will call the above parent listed, If not available, the following

person should be called in the case of an emergency.

Name_____________________________ Relationship to child____________________

Phone Home__________________Work_________________Cell__________________

Medical information: ______________________________________________________

Name of Physician___________________________________Phone________________

ALLERGIES? YES_____NO_____ If yes, please list__________________________

____________________________________________________________________

I hereby warrant that, to the best of my knowledge, my child is in good health, and I assume all

responsibility for his/her health and well-being.

Parent Signature_____________________________________________Date____________

Child Care Registration Release Form