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Child's name Age Birthday

VIEWS: 27 PAGES: 2

									                                   Registration Form

                                        <insert logo here or delete text
                                            box for generic form>




Child’s name:                                                       Age:            Birthday:

Parent/Guardian name(s):

Child’s primary residence:

Home phone:                                               Other phone:

Mother’s employer:

Address:

Mother’s daytime phone:

Father’s employer:

Address:

Father’s daytime phone:

***************************************************************************************************************
Emergency contact:                                                 Relationship:

Emergency contact phone number(s):

Names and phone numbers of persons permitted to pick up your child from the center:

Name:                                          Phone:                      Relationship:

Name:                                          Phone:                      Relationship:

Name:                                          Phone:                      Relationship:

***************************************************************************************************************
Name, address, and phone number of your child’s physician:



Date of last physical exam:

Does your child have any specific health problems that the staff should be aware of? (i.e. vision

or hearing loss, allergies, physical limitations, etc.) If so, please explain:




         Name of person filling out this form:
                                      Registration Form




Please list the names and ages of other members of your family that your child relates to:




List any specific fears, likes, or dislikes your child has that might help us to know him/her better:




How does your child act when ill?


Does your child take naps?                 What is an average naptime?


Has your child had any previous group experiences? (i.e. co-ops, Sunday school, daycare)


What was your child’s reaction to that experience?




Who disciplines your child at home?
What method is used at home?


Is your child fully toilet trained?                 If so, when did this occur?


Does your child have a good appetite?


What are your child’s interests and favorite activities?




Is there any additional information you would like to share?




         Name of person filling out this form:

								
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