Childcare Registration

Child's Name

Nickname

Birthday

Age

Gender

Male Female

Potty Trained

Yes No In Progress

Allergies or Special Needs

Mom's First/Last Name

Mom's Phone

Dad's First/Last Name

Dad's Phone

Person Other Than Parent Bringing Child

Person Other Than Parent Phone

Relationship to Child

Preferred Email

This address will receive a confirmation email

Address

Emergency Contact Name

Emergency Contact Relationship to Child

Emergency Contact Phone Number

Are there any custody issues or legal restrictions we should be aware of?

Yes No

If yes, please explain.

Other than a parent, who is authorized to pick up your child(ren)? The authorized person must be at least 16 years old and have a photo ID.

Description

Please fill out this form and click submit.