Parent/Guardian information for parent to be contacted first in an emergency:

First Name

Last Name

Home Phone

Mobile/Work Phone

Parent/Guardian information for parent to be contacted second in case of an emergency:

First Name

Last Name

Home Phone

Mobile/Work Phone

Child(ren) live(s) with?

Please list the names and phone numbers of 2 additional contacts in the event that neither parent/guardian can be reached.

Emergency Contact Name

Phone

Emergency Contact Name

Phone

Please list the names of all people authorized to pick up your child(ren).

Physical or Dietary Restrictions?

yes no

If applicable, please list the physical and/or dietary restrictions below:

Child 2: Physical or Dietary Restrictions?

yes no

If applicable, please list the physical and/or dietary restrictions of child 2 below.

Child 3: Physical or Dietary Restrictions?

yes no

If applicable, please list the physical and/or dietary restrictions of child 3 below:

Please include any additional information that would be helpful to know when caring for your child.

Total deposit duerequired

$10/day per child. Please send a check the business office in the amount shown below to secure your space.

Please type name of parent/guardian below:required

2018-19 Full-Day Child Care