Entrance Date *

MM

DD

YYYY

Withdrawal Date

MM

DD

YYYY

Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Sex *

Male

Female

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Telephone Number

(###)

###

####

Father's Name *

First Name

Last Name

Father's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's telephone number

(###)

###

####

Father's Address of Employment

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Business Telephone Number

(###)

###

####

Mother's Name *

First Name

Last Name

Mother's address if different from child's

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mothers's telephone number

(###)

###

####

Mother's Address of Employment

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Business Telephone Number

(###)

###

####

Child's Living Arrangements

Both Parents

Father

Mother

Other

Emergency Contact Name 1 *

First Name

Last Name

Emergency Contact Phone 1 *

(###)

###

####

Emergency Contact Name 2

First Name

Last Name

Emergency Contact Phone 2

(###)

###

####

Physician/Clinic’s Telephone Number *

(###)

###

####

My child has special need(s) *

Yes

No

Special accommodation(s) may be required to most effectively meet my child's needs while at this center *

Yes

No

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 *

Yes

No

Parent/Guardian Name *

First Name

Last Name