Child Daycare Registration

Child(ren's) Name:____________________________________________________
Birthdate(s):________________________________________________________
Home Phone:_______________ Email:____________________________________
Home Address:_______________________________________________________

Mother/Guardian's Name:____________________________________
Cell Phone:_______________ Employer:___________________________________
Work Address:______________________________________________________
Work Phone:__________________ Times at work:__________________________
Father/Guardian's Name:_____________________________________________
Cell phone:_____________ Employer:___________________________________
Work Address:_____________________________________________________
Work Phone:________________ Times at work:___________________________

Person's who may be called in case of illness or emergency if parent cannot be reached:
Name                 Relationship      Address    Phone                  __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Person's designated to pick up child:
Name                 Relationship             Address        Phone                              __________________________________________________________________
__________________________________________________________________
*For your child's safety, I will ask for I.D. from people on this list or for a password.
Your child's password is:________________________

Name of Child's Doctor:__________________________ Phone:_________________
Address:____________________________________________________________

Describe any social information or special needs of the child:____________________
___________________________________________________________________
Describe any physical or medical problems of child:____________________________
___________________________________________________________________
Give instructions for the above mentioned problems:____________________________
___________________________________________________________________
In case of serious emergency or illness, when the parent's cannot be reached immediately, I hereby authorize the child care giver to obtain emergency medical care ( physician, dentist, paramedics, or other emergency agents. ) I agree to be responsible for the cost of such emergency medical care. 

Signature of Parent or Guardian:_____________________________________________