Child Care Registration Form – Rising Stars Academy

Child's Info

Date child entered care

Date child left care

Child's Name

Birthdate

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child's parent/guardian info

Child's parent/guardian name

First

Last

Home Phone

Cell Phone

Address where you can be reached while child is in care

Address Line 1

Address Line 2

City

State

Zip Code

Child's other parent/guardian name

First

Last

Home Phone

Cell Phone

Address where you can be reached while child is in care

Address Line 1

Address Line 2

City

State

Zip Code

Other than you, who else has permission to pick up your child?

First

Last

Relationship

Cell Phone

Who does not have permission to pick up your child? If applicable

First

Last

Relationship

Reason

In case of an emergency, I give permission for any of the following individuals to be contacted and my child may be released to any of them.

First

Last

Relationship

Child’s health information

Date of child’s last physical exam

Child’s health care provider

Phone

Special health problems

Yes
No

If yes, please specify

Allergies, including drug reactions

Yes
No

If yes, please specify

Regular medications?

Yes
No

If yes, please specify

Other important information

Yes
No

If yes, please specify

Parent/guardian signature

Signature

Date