School Registration

Child's Application for Enrollment
Date Application Completed:
Date of Enrollment:
Student Information
First Name*
Last Name*
Birth Date*

MonthDayYear
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Doctors Name*

First NameLast Name
Doctors Phone Number*

Area CodePhone Number
Hospital Preference:
I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency. Signature of Parent/Guardian

Clear
Father's Address
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
Address - Same As Child*

YesNo
Mother's Address
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
Number
Address - Same As Child's

YesNo
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?

YesNo
CONTACTS: Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals. Please list NAME, RELATIONSHIP, ADDRESS & PHONE NUMBER
Contact #2
Contact #3
I, as the operator, do agree, to provide transportation to an appropriate medical resource in the event if an emergency, In an emergency situation other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child's parent, guardian, or full-time custodian. SIGN ELECTRONICALLY

Clear
Family religion and/or special preference. Example : Family doesn't celebrate holidays.
Date

MonthDayYear
Should be Empty:

Child's Application for Enrollment

Student Information

Father's Address

Mother's Address