CAAB Child Care Registration Form


  
CHILD’S INFORMATION  
Child’s Full Name: ____________________________________ Birth Date: _____/_____/_____  Address: _____________________________________________ Home Phone: ________________ 
City: _____________________________ State: _________PC/Zip Code: ________________  
Nickname: _______________________________  
PARENT/GUARDIAN INFORMATION  
Mother’s Full Name: _________________________________ Home Phone: __________________ Address: __________________________________________________________________________ City: _____________________________ State: _________PC/Zip Code: ________________ Occupation: _____________________________ Work Phone: ____________________ext._______ Name of Employer________________________ Pager or Cellular Phone: ____________________ Business Address: __________________________________ City: ___________________________ Work Hours: ____________________________ Driver’s License # __________________________  
Father’s Full Name: _________________________________ Home Phone: __________________ Address: __________________________________________________________________________ City: _____________________________ State: _________PC/Zip Code: ________________ Occupation: _____________________________ Work Phone: ____________________ext._______ Name of Employer________________________ Pager or Cellular Phone: ____________________ Business Address: __________________________________ City: ___________________________ Work Hours: ____________________________ Driver’s License # __________________________  
Parent/Guardian with legal custody _________________________________________________ Parents are: Married ___ Living Together___ Divorced ___ Separated ___ Widowed ___ Single ___  Other Household Members: Names: _________________________________ Ages: _________ Relationships ________________ Names: _________________________________ Ages: _________ Relationships ________________ Names: _________________________________ Ages: _________ Relationships ________________    
                                 
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CHILD PICK-UP INFORMATION  
Please list below the people who have *Permission* to pick up your child. *Note:  Anyone picking up your child must have picture ID.  
Name: __________________________ Phone: _________________ Relationship: __________ Name: __________________________ Phone: _________________ Relationship: __________ Name: __________________________ Phone: _________________ Relationship: __________  
Please list those persons who *Do Not Have Permission* to pick up your child. Please explain the reason below or talk to your caregiver so she is aware of the situation.  
Name: __________________________ Phone: _________________ Relationship: __________ Name: __________________________ Phone: _________________ Relationship: __________   
Reason person is not allowed to pick up your child:  Name: __________________________ Reason: ___________________________________________________________________________  
Name: __________________________ Reason: ___________________________________________________________________________   
EMERGENCY CONTACTS Primary Emergency Contact (other than parents or guardian)  Name: ________________________________________________ Home Phone: _______________________________ Work Phone: ____________________________ Relationship to Child: ________________________________________________________________ Address: ___________________________________________________________________________  
Secondary Emergency Contact (other than parents or guardian) Name: ________________________________________________ Home Phone: _______________________________ Work Phone: ____________________________ Relationship to Child: ________________________________________________________________ Address: ___________________________________________________________________________  
Any Special Instructions on how to reach parents: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ EMERGENCY INFORMATION 
                                 
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1. Child’s Physician: ________________________________ Phone: ___________________________ 
2. Preferred Hospital: _______________________________ Phone: ___________________________ 
3. Child’s Dentist: __________________________________ Phone: ___________________________ 
3. Insurance Company: ______________________________ Policy #: _________________________ 
4. Regular Medications: _______________________________________________________________ 
5. Medicine allergic to: _______________________________________________________________ 
6. Food Allergies: ___________________________________________________________________ 
7. Any other Allergies: _______________________________________________________________ 
8. Immunization Record:  Date of Last Immunization: _______________________________________ 
9. Any special health conditions: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________    
OTHER IMPORTANT INFORMATION/PROVISIONS   
Child will need special provisions such as:   
[  ]   Extra curricular activity [  ] Yes [  ] No If yes, please give details: (what activity, when, if transportation is required, specific arrangements to attend with other family members/friends, etc.)   ____________________________________________________________________________  ____________________________________________________________________________  
[  ]   Other provisions we should be aware of: ___________________________________________  ____________________________________________________________________________  ____________________________________________________________________________  
Do you have any outstanding concerns? _________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________