Registration form

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Registration Form

"*" indicates required fields

Contact Information

Child's Full Name:*

Child's Nickname:*

Birthdate:

Date of Enrolment:

Home Phone:

Address:

Mother's Information

Mother's Full Name:

Mother's Home Phone:

Mother's Address:

Mother's Employer

Mother's Employer:

Mother's Occupation:

Hours at Work:

Days at Work:

Work Phone:

Cell Phone:

Employer's Address:

Untitled

Father's Information

Father's Full Name:

Father's Home Phone:

Father's Address:

Father's Employer

Father's Employer:

Father's Occupation:

Hours at Work:

Days at Work:

Work Phone:

Cell Phone:

Employer's Address:

Fill out only if applicable

Parent/Guardian with legal custody:

Do you have a decree on file?:

Parents are:

Primary Emergency Contact

Full Name:

Relationship to child:

Address:

Phone:

Secondary Emergency Contact

Full Name:

Relationship to child:

Address:

Phone:

Person(s) authorized to pick up my child (Besides parents/guardians or emergency contacts)

Person #1:

Person #2:

Person #1:

Daycare references

Has your child ever been in daycare before?:

If so, why did you leave?:

Name of previous provider:

Phone number of previous provider:

Consent to Emergency First Aid & Transportation

I hereby give my permission that my child, may be given emergency treatment by Creative All Stars Childcare I also give permission for my child to be transported by car or ambulance to an emergency center for treatment.

yes

Consent to Medical Care & Treatment

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

yes

Consent to Photograph

yes

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

Child's Physician:

Phone:

Preferred Hospital:

Phone:

Insurance Company:

Policy Number:

Regular Medications:

Blood Type:

Medicine Allergic to

Food Allergies:

Other Allergies:

Special Health Conditions:

Carecard Number:

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

Number of days per week childcare is needed:

Days of week care is needed:

What time will you bring your child to daycare?:

What time will you pick-up your child?:

For Out of School Care

What School does your child attend?

Email*

Comments

Agreement

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

yes

Phone

This field is for validation purposes and should be left unchanged.

Registration form