Registration Form

First day of attendance
Last day of attendance
Child's Name *Please provide last name, first, middle
Birthdate
Gender
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Father's Name
Business Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Mother's Name
Business Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Allergies
Significant Medical Information or Special Needs
Physician Name
Physician Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Physician Phone
Hospital
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
I give my permission for Emergency Medical transportation
YesNo
I give my permission for Emergency Medical treatment
YesNo
Emergency Contact 1 Name a Local Emergency Contacts other than parents or guardians
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Emergency Contact 1 Name a Local Emergency Contacts other than parents or guardians
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone

At the end of the day or during any day, my child may be released to the person or persons that have legal custody or the following persons: (It is understood that identification will be verified at the time of pick up.)
Full Name
Full Name
Full Name
Full Name
I have read and understand the parent handbook: *
YesNo
Signature of Parent or Guardian (This can be completed at the center)
Date
Signature of Director or Administrator (This will be completed at the center)
Date

Stepping Stones Daycare and Learning Center