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
This page maintained by Patricia Hinton of
Greatest Resource Home Childcare and Preschool
located in Goodyear Arizona 85395
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