Child Care Registration Form
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3F
R
F
AMILY
EGISTRATION
ORM
1
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SHEET
OF
Parent/Guardian Information
Registration Date:
Mother/Guardian First Name:
M.I.
Last Name:
Address:
Occupation:
Home Phone: (
)
Employed By:
Office Phone: (
)
Work Address:
Work Hours:
Cell Phone: (
)
[ ] Custodial Parent (If married, mark both parents)
Mother’s SS#:
Email:
Driver’s License #:
st
nd
Preferred PIN number for checking in/out
(4 digits, numbers only) 1
choice __ __ __ __ 2
Choice __ __ __ __
Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other_____________________
Father/Guardian First Name:
M.I.
Last Name:
Address:
Occupation:
Home Phone: (
)
Employed By:
Office Phone: (
)
Work Address:
Work Hours:
Cell Phone: (
)
[ ] Custodial Parent (If married, mark both parents)
Father’s SS#:
Email:
Driver’s License #:
st
nd
Preferred PIN number for checking in/out
(4 digits, numbers only) 1
choice __ __ __ __ 2
Choice __ __ __ __
Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other_____________________
Child Information
st
1
Child First Name:
M.I.
Last Name:
Name child prefers to be called:
Grade/Class:
Child’s Address:
Gender: [ ] Male [ ] Female Date of Birth:
Child’s S.S. #:
List any existing medical conditions, medication and/or special attention your child may require?
Allergies:
Pediatrician’s Name:
Phone: (
)
Address:
Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No
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