Fillable Form Lic 995 - Child Care Re-Enrollment Form

Form Lic 995 - Child Care Re-Enrollment Form - 2015-2016

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Triunfo YMCA

Child Care

31225 La Baya Drive #106

Westlake Village, CA 91362

(818)707-YMCA (9622)

Re-Enrollment Form

Fax: (818) 706-0282

2015-2016

Tax ID #95-2305501

Child’s Last Name _________________________________

First Name_____________________________________

Update ALL information below for 2015-2016 School year.

Additional authorized persons who may be called in an emergency and/or take your child from the facility. Only those listed

below will be allowed to sign out the child.

All authorized persons must be 18 years or older and have photo identification

1. Name: ____________________________________________________________________ Phone # ______________________________________________________________

2. Name: ____________________________________________________________________ Phone # ______________________________________________________________

3. Name: ____________________________________________________________________ Phone # ______________________________________________________________

4. Name: ____________________________________________________________________ Phone # ______________________________________________________________

5. Name: ____________________________________________________________________ Phone # ______________________________________________________________

Child’s Doctor: ________________________________________________________ Doctor’s Phone: ____________________________________________________________

Address: _______________________________________________________________ City:____________________________________________ Zip:_______ __________________

Child’s Dentist: ____________________________________________________________Dentist’s Phone: _____________________________________________________________

Address: _______________________________________________________________ City:____________________________________________ Zi p:_________________________

Insurance Company: __________________________________________________ Policy #: ___________________________________________________________ ________

Is there anything else that we should know about your child?:

_____________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________ ________________________________

I have read and understand the above information and have completed this form to the best of my ability and will continue to

keep the YMCA file updated with any changes to this information.

Parent’s Signature ____________________________________________ Date _______________________________