Family Registration Card



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: List any existing medical conditions, medication and/or special attention your child may require Allergies: Pediatrician’s Name: Phone: ( ) Address: Photographs: May we take and maintain a photo of your child for security purposes Yes No FAMILY REGISTRATION FORM SHEET 3 OF 3 Emergency Contacts Authorized Pickup Persons: 1st Contact/Pick Up Name: Phone: Relationship to the Child: PIN for check in/out (4 digits, numbers only) Able to pick up all children in the family Not able to pick up the following children: 2nd Contact/Pick Up Name: Phone: Relationship to the Child: PIN for check in/out (4 digits, numbers only) Able to pick up all children in the family Not able to pick up the following children: 3rd Contact/Pick Up Name: Phone: Relationship to the Child: PIN for check in/out (4 digits, numbers only) Able to pick up all children in the family Not able to pick up the following children: 4th Contact/Pick Up Name: Phone: Relationship to the Child: PIN for check in/out (4 digits, numbers only) Able to pick up all children in the family Not able to pick up the following children: Tuition / Payment Information: Current Tuition Amount: Weekly Bi-Weekly Monthly Other Please outline below whom is responsible for payment of tuition and fees..




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