Registration Form
Please print clearly with blue or black ink.


Child’s Full Name: ____________________________
Birth Date: _________________
Address: ___________________________________
Home Phone: _________________
City: ________________________________ State: _____Zip Code: _________________
Nickname: _______________________________
Social Security #: __________________


Mother’s Full Name: _______________________
Home Phone: ___________________
Address: ________________________________
City: _____________________________ State: _____ Zip Code: __________________
Driver’s License # _______________________
Social Security #: __________________
Occupation: _______________________________
Name of Employer: ___________________
Work Phone ___________ext.___
Pager or Cellular Phone:___________________
Business Address: ______________________________________________________________
Work Hours: _______________________


Father’s Full Name: _______________________
Home Phone: ___________________
Address: ________________________________
City: _____________________________ State: _____ Zip Code: __________________
Driver’s License # _______________________
Social Security #: __________________
Occupation: _______________________________
Name of Employer: ___________________
Work Phone ___________ext.___
Pager or Cellular Phone:___________________
Business Address: ______________________________________________________________
Work Hours: _______________________


Parent/Guardian with legal custody
_________________________________________________

Parents are:
Married _____
Divorced _____
Separated _____
Widowed _____
Single _____


Other Household Members:
Name: __________________________________
Age: _________
Relationship ________________
Name: __________________________________
Age: _________
Relationship ________________


Emergency Contacts
(Within 20 mile radius of daycare other than parent or guardian)
Primary Emergency Contact (other than parents or guardian)
____________________________________
Home Phone: __________________________________
Work Phone: __________________________
Relationship to Child: ___________________________________________________________________
Address:______________________________________________________________________________

Secondary Emergency Contact (other than parents or guardian)
____________________________________
Home Phone: __________________________________
Work Phone: __________________________
Relationship to Child: ___________________________________________________________________
Address:______________________________________________________________________________


Person (s) authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name: __________________________________
Comment _____________________________________________________________
_____________________________________________________________
_____________________________________________________________



Person (s) NOT authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name: __________________________________
Comment ______________________________________ _____________________________________________________________
_____________________________________________________________
_____________________________________________________________



Name of any other school child attends: ________________________
Phone: __________________________


Emergency Information
1. Child’s Physician: ________________________________
Phone: _____________________

2. Preferred Hospital: ________________________________
Phone: _____________________

3. Insurance Company: ______________________________
Policy #: _____________________

4. Regular Medications: ___________________________________________________________


5. Blood Type: _______________


6. Medicine allergic to: ___________________________________________________________

7. Other Allergies: _______________________________________________________________

8. Any special health conditions: ____________________________________________________

Parent/Guardian (Mother) ______________________________________________

Parent/Guardian (Father)_______________________________________________



I understand this is a legally binding agreement/contract, and I have agree to and understand all policies within the Parent Handbook and will be responsible for all payments. Click here to go back to the Little Treasures Page