Child Registration

Child Registration

Complete the child registration form using the child’s, parent/guardian’s, custody, medical, emergency contact, authorization, agreement, signature, and attendance information from the CDC Child Registration. Please complete a registration form for each child that will be participating. At the end of the form, there will be a $50 deposit to be paid to hold you child's spot. First week will be August 10-14, 2026.
Choose which program this child will be participating in.
Child Information
Child's Name (first and last)
Nickname
Date of Birth

MonthDayYear
Date
Sex
Place of Birth
Birth Certificate Number
Birth Certificate Date Issued

MonthDayYear
Date
Other Form of Proof of Identity
Date Documentation Viewed

MonthDayYear
Date
Person Viewing Documentation
Date of Notification of Local Law-Enforcement Agency

MonthDayYear
Date
Child Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Chronic Physical Problems / Pertinent Developmental Information / Special Accommodations Needed
Previous Child Day Care Programs and Schools Attended
If Child Attends this Center and Another School/Program, Give Name of School/Program
Grade or Class Level
Parent / Guardian Information
Parent 1 Name
Parent 1 Place Employed
Parent 1 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent 1 Home Address
Parent 1 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Name
Parent 2 Place Employed
Parent 2 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Home Address
Parent 2 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Legal Custody
Person(s) or Agency Having Legal Custody of Child
Legal Custody Home Address
Legal Custody Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Legal Custody Work Address
Legal Custody Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical & Allergy Information
Allergies or Intolerances to Food, Medication, etc. and Action to Take in an Emergency
Child’s Physician
Child’s Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts
Emergency Contact 1 Name
Emergency Contact 1 Address
Emergency Contact 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Name
Emergency Contact 2 Address
Emergency Contact 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Pick-Up Authorization
Person(s) Authorized To Pick Up Child
Person(s) NOT Authorized To Pick Up Child
Signatures & Dates
Parent(s) or Guardian(s) Signature
Parent(s) or Guardian(s) Signature Date

MonthDayYear
Date
Administrator of Center Signature
Administrator of Center Signature Date

MonthDayYear
Date

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Deposit for 26-27 Childcare

$50.00 Quantity

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Total

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Child Registration

Child Information

Parent / Guardian Information

Legal Custody

Medical & Allergy Information

Emergency Contacts

Pick-Up Authorization

Signatures & Dates

My Products

Credit Card