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SAFETY FIRST

We're taking extra measures to ensure your children are safe in our nursery. Learn More

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Entrance Date

Withdrawl Date

Childs Full Name

Gender

Male

Female

Age

Date of Birth

Address

Phone

Mothers Name

Mothers Phone Number

Mothers Email

Mothers Address (if different from childs)

Mother's Place of Employment

Mothers Work Phone

Mothers Employer's Address

Fathers Name

Fathers Phone Number

Fathers Email

Fathers Address (if different from childs)

Fathers Place of Employment

Fathers Work Phone

Fathers Employer's Address

Child's Living Arrangements: (check one)

Both Parents

Mother

Father

Other

Child's Legal Guardian(s): (check one)

Both Parents

Mother

Father

Other

The child may be released to the person(s) signing this agreement or to the following:

Name of additional person #1 child is being released to

Address of additional person #1 child is being released to

Phone Number of additional person #1 child is being released to

Relationship to the Child of additional person #1

Relationship to the Parent/Guardian of additional person #1

Name of additional person #2 child is being released to

Address of additional person #2 child is being released to

Phone Number of additional person #2 child is being released to

Relationship to the Child of additional person #2

Relationship to the Parent/Guardian of additional person #2

Person(s) to contact in the case of emergency when parent or guardian cannot be reached:

Emergency Contact #1 Name:

Emergency Contact #2 Name:

Emergency Contact #3 Name:

Emergency Contact #1 Phone Number

Emergency Contact #2 Phone Number

Emergency Contact #3 Phone Number

Name of Public or Private School child attends, if any:

Child's doctor or clinic name:

Doctor/clinic Telephone Number:

My child has the following special needs:

The following special accommodation(s) may be required to most effectively meet my child's needs while at the center:

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre existing illness, allergies, or health concerns:

Thank you! We will be in contact soon.

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