» Registration Form

This field is hidden when viewing the form
Account ID

This field is hidden when viewing the form

Logo URL

This field is hidden when viewing the form

Director Email

Center Name

This field is hidden when viewing the form

Contact ID

Tell us about your child

Child's Name*

First Middle Last Nickname

Child Date of Birth*

Gender*

Male

Female

Language(s) spoken at home*

Child's Home Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Please list family members your child lives with, including the names and ages of siblings:

Tell us about you: Primary contact

Primary Contact Name*

First Last

Relationship to Child*

Primary Phone*

Secondary Phone

Email Address*

Address*

Same as Child's Address

Street Address Address Line 2 City State ZIP Code

Employer's Address and Phone Number

Tell us about you: Second contact

Secondary Contact Name

First Last

Relationship to Child

Primary Phone

Secondary Phone

Email Address

Address

Same as Child's Address

Street Address Address Line 2 City State ZIP Code

Employer's Address and Phone Number

Guardian Approval

We will only release your child to the parent or guardians listed on this application. If you would like to give permission for another adult 18 or older to pick up your child, please fill in the questions and answers below so that we can do that over the phone. I.D. will be required of anyone picking up your child on your behalf.

Security Question 1:

Security Answer 1:

Security Question 2:

Security Answer 2:

Who Are Emergency Contacts Authorized To Pick Up Your Child (18 or older)?

Contact #1 Name*

First Last

Contact #1 Relationship*

Contact #1 Address*

Street Address Address Line 2 City State ZIP Code

Contact #1 Primary Phone*

Contact #1 Secondary Phone

Contact #2 Name

First Last

Contact #2 Relationship

Contact #2 Address

Street Address Address Line 2 City State ZIP Code

Contact #2 Primary Phone

Contact #2 Secondary Phone

Contact #3 Name

First Last

Contact #3 Relationship

Contact #3 Address

Street Address Address Line 2 City State ZIP Code

Contact #3 Primary Phone

Contact #3 Secondary Phone

Contact #4 Name

First Last

Contact #4 Relationship

Contact #4 Address

Street Address Address Line 2 City State ZIP Code

Contact #4 Primary Phone

Contact #4 Secondary Phone

List any current medications

Health Insurance Provider

Date of last physical examination

Medical Provider

Medical Care Provider Name*

Practice / Clinic Name

Medical Provider Phone*

Provider Address*

Street Address Address Line 2 City State ZIP Code

Preferred Hospital

Preferred Hospital / Clinic

Dentist Information

Dentist Name

Dentist Phone

Dentist Address

Street Address Address Line 2 City State ZIP Code

Allergies

Check below for each of your child's allergies, Then list possible reactions, If any allergies are severe or life threatening, please let your director know immediately.

Allergies

Medications

Food

Respiratory

Bee Sting

Other

Allergic Reaction Info

Transportation Information (For School-Age Children Only)

Name of School

Grade

School Start Time

School End Time

Transportation Provided By

Elementary School

Parent/Guardian

Center

Other (Specify)

Other Transportation Provider*

School's Address

Street Address Address Line 2 City State ZIP Code

School's Phone

Hours of Care (e.g., 8am-5pm)

Monday

Tuesday

Wednesday

Thursday

Friday

Parent/Guardian Responsible for Payment 1*

Social Security #*

Parent/Guardian Responsible for Payment 2

Social Security #

You may still need to complete some additional paperwork that is state/school specific. We will contact you if that additional paperwork is needed.

Signature*

Date