Registration Form

Child’s Name

Birthday

Start Date

Home Address

Home Phone

Mother’s Name

Mother’s Business Phone

Cell

Mother’s Business Address

Father’s Name

Father’s Business Phone

Cell

Father’s Business Address

Has your child attended a day care center previously?

Yes No

If so, Name of center

From

Who will pick up your child

Who should be contacted in case of emergency

If you cannot be reached, who can act in your behalf

Doctor’s Name

Phone No.

I hereby release The Children’s Center from any and all liabilities.

I acknowledge that the Guide to Regulated Child Care can be found on the website deeppink-horse-949941.hostingersite.com under Forms.

Signature

Date