SUMMER DAY CARE

SUMMER DAY CARE

Registration Information
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Age
Nickname
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
My child will be in:
Select Group
Select one
My Child will be attending: check all that apply
I will need child care from

FromTo
Mother/Guardian

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
Father/Guardian

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
Emergency Numbers

Please list in the order you want them called
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Name of Health Insurance Company
Policy Number
Group Number
Is your child currently being treated for any illness or injury?
If "Yes" please explain
Is your child currently taking any medication?
If "Yes" please explain
Does your child have any allergies?
If "Yes" please explain
Please list the names of people who will be authorized to pick up your child
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
The Open Door Church has my permission to seek emergency medical treatment for my child if needed.
Digital Signature here indicates your approval
Should be Empty:

SUMMER DAY CARE

My child will be in:

Emergency Numbers

Please list the names of people who will be authorized to pick up your child

The Open Door Church has my permission to seek emergency medical treatment for my child if needed.