| Child's Full Name: __________________________________ Birth Date: __________________ Address: _________________________________________ Home Phone: _______________ City: ____________________________ State: _______________ Zip Code: ______________ Nickname: ____________________________________________________________________ Mother's Full Name: _______________________________ Home Phone: _________________ Address: _____________________________________________________________________ Occupation: ____________________________________ Work Phone: ___________________ Name of Employer: ______________________________ Cell Phone: ____________________ Business Address: _______________________________ City: _________________________ Work Hours: _______________________________ Driver's License #: ___________________ Father's Full Name: ______________________________ Home Phone: ___________________ Address: _____________________________________________________________________ Occupation: ___________________________________ Work Phone: ____________________ Name of Employee: _____________________________ Cell Phone: _____________________ Business Address: ______________________________City: ___________________________ Work Hours: ________________________________ Driver's License #: __________________ Parents are: ___Married, ___Living Together, ___Divorced, ___Separated, ___Widowed, ___Single Parent/Guardian with legal custody ________________________________________________ It is helpful to furnish a copy of the divorce decree or custody agreement which will be kept in your child's file and all information will be confidential. Without a copy of the official papers, I may not be able to prevent your child from leaving with his/her non-custodial parent. Emergency Contracts (Any individual other than parent or guardian that is within 30 mile radius of daycare) Primary Emergency Contact: _____________________________________________________ Home Phone: ____________________________ Work Phone: _________________________ Please indicate which number is best for the hours your child is in my care. _________________ Relationshihp to Child: __________________________________________________________ Address: _____________________________________________________________________ Secondary Emergency Contact: ___________________________________________________ Home Phone: ____________________________ Work Phone: __________________________ Please indicate which number is best for the hours your child is in my care: _________________ Relationship to Child: ___________________________________________________________ Address: _____________________________________________________________________ Allergies / Special Needs or Instructions / Medications: _________________________________ ____________________________________________________________________________ Other Household Members: (names, ages, relationships): _______________________________ _____________________________________________________________________________ Adults authorized to pick up my child: _______________________________________________ _____________________________________________________________________________ Kid Code: _____________________ (Secret word between parent & child for identification and pick up) Name of other school child attends: ___________________________ Phone: _______________ Immunization records: _____on file, _____complete, ____incomplete Registration Fee: ________________ due at time of signing |
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| This page maintained by Patricia Hinton of Greatest Resource Home Childcare and Preschool located in Goodyear Arizona 85395 |
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