Childcare Registration Form printable pdf download

Name of Facility:

CHILD'S STARTING DATE:

SEX:

DATE OF BIRTH:

______/ ______/ ______

M ____ F ____

______/ ______/ ______

NAME OF CHILD:

______________________________________________________________________________________________

(Surname)

(Given Names)

(Also Known As)

Name the Child responds to: ____________________________________________________________________________________________

Address

____________________________________________________________________________________________________________

Postal code

__________________________________________________ Phone: _________________________________________________

Person(s) with whom the child lives (adults and children)

_____________________________________________________________________

Child's first language: ________________________________ Other languages: ___________________________________________________

Parent(s) / guardian(s):

Name: __________________________________ Home phone: _____________________________ Cell phone: ________________________

Work phone: ____________________ Days/hours of work: ________________________________ E-mail: ____________________________

Name: __________________________________ Home phone: _____________________________ Cell phone: ________________________

Work phone: ____________________ Days/hours of work: ________________________________ E-mail: ____________________________

Person(s) authorized to pick up the child and be contacted in case of emergency. These people should be available during hours of care.

(include mother / father / guardian):

Name: ___________________________________________________________________ Relationship to child: _________________________

Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________

Name: ____________________________________________________________________ Relationship to child: ________________________

Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________

Name: ____________________________________________________________________ Relationship to child: ________________________

Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________

Name: ____________________________________________________________________ Relationship to child: ________________________

Home phone: ____________________________ Work phone: ______________________________ Cell phone: _________________________

If appropriate, list an English speaking contact:

Name: ____________________________________________________________________ Phone: ____________________________________

Has the child previously attended davcare/preschool?

YES

Comments: ______________________________________________________________________________________

Comments/instructions to help us care for your child. (Please feel free to add additional pages.):

Toileting/Diapering (special words): _______________________________________________________________________________________

Rest Time (special comfort – toy/blanket): __________________________________________________________________________________

Eating/Mealtime (include food likes/dislikes): _______________________________________________________________________________

Fears: _______________________________________________________________________________________________________________

CCFL2 09-09

Childcare Registration Form

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