Child Registration Application Page 2

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Office use only
Admission Date_____________________
Group Entering_____________________
Deposit Amount_____________________
ACD#_____________________________
Start Date__________________________
Co-Pay____________________________
CHILD REGISTRATION APPLICATION
Location: Sunset Park Borough Park Coney Island Prospect Heights
Child’s Full Name __________________________ Date of Birth___________________________ Sex M F
Address___________________________ Apt#________ City_______________ State________ Zip_________
PARENTS IS/ARE
Married Divorced Separated Single
CHILD LIVES WITH Both Parents Father Mother
Father_____________________ SS#______________
Mother_____________________ SS#_____________
Address_____________________________________
Address_____________________________________
Home ( )______________ Cell( )_______________
Home ( )______________ Cell( )_______________
Email_______________________________________
Email_______________________________________
EMERGENCY CONTACT 1
Name_______________________ Relationship to child_________________ Tel( )______________________
EMERGENCY CONTACT 2
Name_______________________ Relationship to child_________________ Tel( )______________________
CHILDS DOCTOR & MEDICAL INFORMATION
Name____________________ Address_______________________ Tel( )_____________________________
Any medical problems YES NO _____________________________________________________________
Medications YES NO ___________________________________ Allergies YES NO_________________
PICK UP INFORMATION (aside from Mother/Father)
Name_______________________________________
Name_______________________________________
Relation to child______________________________
Relation to child______________________________
Tel( )_______________ Tel( )_________________
Tel( )_______________ Tel( )_________________
Name_______________________________________
Name_______________________________________
Relation to child______________________________
Relation to child______________________________
Tel( )_______________ Tel( )_________________
Tel( )_______________ Tel( )_________________
By signing below, you agree that this is a legally binding form. Providing false information will result in
termination of childcare services, and forfeiture of retainer.
Father/Guardian's Signature
Date
Mother/Guardian's Signature
Date
OFFICE USE ONLY
NOTE:_____________________________________________________________________________________________________
____________________________________________________________________________________________________________

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