Please Print Clearly with Blue Or Black Ink

Registration Form

Please print clearly with blue or black ink.

Child’s Full Name: ______Birth Date: ______
Address: ______Home Phone: _( )______
City: ______State: _____Zip Code: ______
Nickname: ______Social Security #: ______
Mother’s Full Name: ______Home Phone: ( )______
Address: ______Social Security #: ______
City: ______State: _____Zip Code: ______
Occupation: ______Work Phone: ( )______ext.______
Name of Employer: ______Pager or Cellular Phone: ( )______
Business Address: ______City: ______
Work Hours: ______Driver’s License # ______
Father’s Full Name: ______Home Phone: ( )______
Address: ______Social Security #: ______
City: ______State: _____ Zip Code: ______
Occupation: ______Work Phone: ( )______ext.______
Name of Employer: ______Pager or Cellular Phone:______
Business Address: ______City: ______
Work Hours: ______Driver’s License # ______

Parent/Guardian with legal custody ______

Parents are: Married ___Living Together___Divorced ___Separated ___Widowed ___Single___

Other Household Members:

Names: ______Ages: ______Relationships______

Emergency Contacts

Primary Emergency Contact (other than parents or guardian) ______

Home Phone: ______Work Phone: ______

Relationship to Child: ______

Address:______

Secondary Emergency Contact (other than parents or guardian) ______

Home Phone: ______Work Phone: ______

Relationship to Child: ______

Address:______

Person (s) authorized to pick up my child: (Besides parents, guardians, or emergency pick-ups)

Name: ______Comment______

Kid Code: ______(Secret word between parent & child for identification and pick up)

Person (s) NOT authorized to pick up my child: (Besides parents, guardians, or emergency pick-ups)

Name: ______Comment ______

Name of other school child attends: ______Phone: ______

Emergency Release

Consent to Emergency First Aid & Transportation:

I hereby give permission that my child, ______, may be given emergency treatment by a staff member at Kid's Play Activity Center. I also give permission for my child to be transported by car, ambulance, or Aid car to an emergency center for treatment, and agree to hold ______and its employees harmless.

Parent’s Signature ______Date: ______

Consent to Medical Care and Treatment:

In the event that I cannot be contacted immediately, medical of surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician, and hold ______and its employees harmless.

Parent’s Signature ______Date: ______

Emergency Information

1. Child’s Physician: ______Phone: ( )______

2. Preferred Hospital: ______Phone: ( )______

3. Insurance Company: ______Policy #: ______

4. Regular Medications: ______
5. Blood Type: ______

6. Medicine allergic to: ______

7. Food Allergies: ______

8. Any other Allergies: ______

9. Any special health conditions: ______

Field Trip Permission

I hereby request that my child, ______, be permitted to participate in field trips, to the park, or any other activities that would involve taking the child outside of the daycare for his/her benefit in attendance at this facility.

Parent’s Signature: ______Date: ______

Persons signing contract are responsible for payment:

I understand this is a legally binding contract, and I have read it and understand it.

Parent/Guardian (Mother) ______Parent/Guardian (Father)______