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
Registration Form
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Greatest Resource Home Childcare and Preschool
located in Goodyear Arizona 85395 
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