Child�s Full Legal Name ________________________________________________
Date Enrolled____________________
Sex _________ Birthdate _____________________
Address ________________________________________City ____________________ Zip ____________
Who has legal custody? ______________________________________________
Mother�s Name _______________________________________Phone _____________________________
Pager ______________________ Cell phone ________________________
Home Address _______________________________ City ____________________ Zip ____________
Place of employment _____________________________Phone _________________________
Address ____________________________________ City _____________________ Zip ____________
Father�s Name __________________________________ Phone _____________________________
Pager ______________________ Cell phone ________________________
Home Address _________________________________ City ____________________ Zip ____________
Place of employment ______________________________ Phone _________________________
Address _____________________________________ City _____________________ Zip ____________
Internet Address for Mother ___________________________
Internet Address for Father _________________________
Persons permitted to remove child:
Name _______________________________
Address____________________________ Phone ________________
Name _______________________________
Address____________________________ Phone ________________
Person to be notified IN CASE OF EMERGENCY when parent or guardian cannot be reached
Name _______________________________
Address____________________________ Phone ________________
Child�s Physician/Health Care Resource ____________________________________________________________________
Address ______________________________________________________ Phone___________________
Does your child have any if the following problems?Please Check
Allergies ____ Earaches ___Diabetes ____Vomiting/Diarrhea ____Skin Problems ____Eating Problems
Frequent Sore Throats/Colds ____ Other Chronic Conditions ________________________
Please Explain___________________________________________________________________________
Physical or Mental Disabilities ___________________________________________________________________________
List all identifying scars, birthmarks, skin discoloration�s ______________________________________________________
Special Needs of your child ______________________________________________________________________________
Instructions regarding toilet training _______________________________________________________________________
Child�s habits, fears, etc. ________________________________________________________________________________
____________________________________________________________________________________________________
Any other information that you wish known _________________________________________________________________
_________________________________________________________________________________________________
I give permission to consult the health care resource listed above in the case of emergency if parent cannot be reached.
________________________________________________________________ Date ____________________________
Signature of Parent or Legal Guardian