“Where loving and learning goes hand in hand”

Registration Form

Child’s Name __________________________________ Birthday ____/____/____

            (include first, middle and last name)

Address _____________________________________ Phone ______-_________

            (include city and zip code)

Date of Admission: ___/___/___

Days in Care: ____________________ Hours in Care: ______ a.m. until ______ p.m.

Cost:  _________________________

Mother’s Name _______________________________ Birthday ____/____/____

Address _____________________________________ Phone ______-_________

S.S.# _____-____-_______ D.L.# __________________ Work Phone ( )

_______-________

Employer ______________________________________________________

                            (include full name and address including city and zip)

Address ______________________________________________________

Pager # ( ) ________-_____________ Mobile # ( )_________-___________

Does the child(ren) live with the mother? (circle one) Yes No

Father’s Name _______________________________ Birthday ____/____/____

Address ___________________________________ Phone _____-_________

S.S.# _____-____-_______ D.L.# _______________ Work Phone ( ) _____-________

Employer __________________________________________________________

                            (include full name and address including city and zip)

Address __________________________________________________________

Pager # ( ) ________-_____________ Mobile # ( ) _________-___________

Does the child(ren) live with the father? (circle one) Yes No

Please provide the following information for any other adults who live with the child:

Name ____________________________ Relation to Child ___________________

S.S.# _____-____-________ D.L.# _______________ Work Phone ( ) _____-________

2. Name __________________________ Relation to Child ____________________

S.S.# _____-____-_______ D.L.# ________________ Work Phone ( ) ______-_______

Persons authorized to pick up child(ren) / Emergency contacts if parents cannot be reached:

1. Name: __________________________ Relation to child: _____________________

D.L.# _______________ Home Phone: _______-________ Work Phone: ______-________

2. Name: __________________________ Relation to child: _______________________

D.L.# _______________ Home Phone: _______-_________ Work Phone: ______-________

3. Name: __________________________ Relation to child: _________________________

D.L.# _______________ Home Phone: _______-_________ Work Phone: ______-________

**Please provide a copy of the drivers license for each of these people if  possible!

Please list any special problems that your child may have, such as allergies, existing illnesses, previous illnesses, injuries during the past twelve months, any medications taken for long term use, and any other information which SSCC should be aware of:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

In the event that I cannot be reached to make arrangements for emergency medical or dental attention, I authorize  person in charge, to take my child to the nearest available hospital or health clinic.

Child’s Physician _______________________________ Phone ( ) _______-___________

Address _________________________________________________________________

_________________________________________________________________________

    Signature of Parent or Legal Guardian  _____________________________      

     Date ________________________________________________________

TRANSPORTATION:

I hereby give my consent for my child to be transported and supervised by  SSCC staff or volunteers on field trips, to and from school, and any other outings.

____________________________________________         _________________

    Signature of Parent or Legal Guardian                         Date

HEALTH REQUIREMENTS:

A current copy of each child’s immunization records must be kept on file and

updated as required.

SCHOOL AGE CHILDREN:

My child attends the following school and his/her immunization record is on file

at the following school and all immunizations and tuberculosis test results are

current.

Name of School _______________________________________ Phone _______-__________

School Address ______________________________________________________________

____________________________________________         _________________

Signature of Parent or Legal Guardian                                    Date