Registration Form - Kids Harbor

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Registration Form
Start date:
Classroom Assignment:_
Child Information:
Child’s Name:
Nickname:
Sex:
Male
Female
Birth Date:
Age:
Address:
City:
State:
Zip:
Parent/Guardian Information:
Mother’s Name:
Marital Status:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Alternate Phone:
Email:
Employer:
Work hours:
Address:
City:
State:
Zip:
Work Phone:
Email:
Father’s Name:
Marital Status:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Alternate Phone:
Email:
Employer:
Work hours:
Address:
City:
State:
Zip:
Work Phone:
Email:
Authorized Alternate Pick-Up:
1. Name:
Relationship to child:
Phone:
Address:
2. Name:
Relationship to child:
Phone:
Address:
3. Name:
Relationship to child:
Phone:
Address:
Photo I.D. will be required for all authorized pick-ups. Written permission is required for any
person, other than those listed above, to pick up your child. Verbal requests cannot be
permitted.

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