Date child entered care Child Care Registration Form Child’s name Last First Middle Name (Nickname) used Street address City Child’s parent/guardian name home phone ( ) - Street address Address where you can be reached while child is in care Child’s parent/guardian name home phone ( ) - Address where you can be reached while child is in care Name cell phone ( ) City cell phone ( ) City City Birthdate Zip code - City Street address Name: Relationship: Date child left care alternative phone ( ) Zip code Zip code - alternative phone ( ) Zip code Zip code Other than you, who else has permission to pick up your child Address Telephone number Home: ( ) Cell: ( ) Alternative: ( ) - Name: Relationship: Home: ( ) Cell: ( ) Alternative: ( ) Name: Home: ( ) Relationship: Cell: ( ) Alternative: ( ) Name: Home: ( ) Relationship: Cell: ( ) Alternative: ( ) 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..
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