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Registration Form

The document is a registration form collecting contact information for parents/guardians and their children. It requests the names, addresses, phone numbers, occupations and employers of the parents/guardians. For each child, it collects their name, address, gender, date of birth, medical conditions, allergies and pediatrician information. It also asks for emergency contact information and authorized pickup persons.

Uploaded by

lkbecker
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
117 views2 pages

Registration Form

The document is a registration form collecting contact information for parents/guardians and their children. It requests the names, addresses, phone numbers, occupations and employers of the parents/guardians. For each child, it collects their name, address, gender, date of birth, medical conditions, allergies and pediatrician information. It also asks for emergency contact information and authorized pickup persons.

Uploaded by

lkbecker
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REGISTRATION FORM

Registration Date:____________ Mother/Guardian First Name: Address: Occupation: Employed By: Work Address: Email: Home Phone: ( Office Phone: ( Work Hours: ) ) Cell Phone: ( ) M.I. Last Name:

Father/Guardian First Name: Address: Occupation: Employed By: Work Address: Email:

M.I.

Last Name:

Home Phone: ( Office Phone: ( Work Hours:

) ) Cell Phone: ( )

Child Information 1 Child First Name: Name child prefers to be called: Childs Address: Gender: [ ] Male [ ] Female Date of Birth: List any existing medical conditions, medication and/or special attention your child may require?
st

M.I.

Last Name: Grade/Class:

Allergies: Pediatricians Name: Address: Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No 2nd Child First Name: Name child prefers to be called: Childs Address: Gender: [ ] Male [ ] Female Date of Birth: List any existing medical conditions, medication and/or special attention your child may require? M.I. Last Name: Grade/Class: Phone: ( )

Allergies: Pediatricians Name: Address: Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No Phone: ( )

3 Child First Name: Name child prefers to be called: Childs Address: Gender: [ ] Male [ ] Female Date of Birth:

rd

M.I.

Last Name: Grade/Class:

List any existing medical conditions, medication and/or special attention your child may require?

Allergies: Pediatricians Name: Address: Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No Phone: ( )

Emergency Contacts & Authorized Pickup Persons: 1 Contact/Pick Up Name: ___________________________________________ Phone: _________________ Relationship to the Child: __________________________ [ ] 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: __________________________ [ ] 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: __________________________ [ ] 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: __________________________ [ ] Able to pick up all children in the family [ ] Not able to pick up the following children:________________________________________________________
st

Lisa Becker

824 W. Turnpike Ave, Bismarck, ND 58501 701-258-5094

email:[email protected]

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