CHILD DATA FORM:
Child’s Name:________________________ Gender:___________ Date of Birth:______________
Home Address:____________________________________________________________________________
Mailing Address (if different from above):_____________________________________________________
____________________ Child’s Primary Language:____________________________________________
Child’s Physician:________(name)__________________________________________________(phone #)________
Allergies:__________________________________________________________________________________
Religious Observances/Restrictions:_________________________________________________________
PARENT/LEGAL GUARDIAN INFORMATION:
Name:____________________________________ Relationship to Child:__________________________
Authorized to Pick Up Child? YES NO
Address (if different from above):____________________________________________________________
Home Phone Number:________________________ Work Phone Number:______________________
Mobile Phone Number:_________________________ Primary Language:________________________
Email Address:____________________________________________________________________________
Name:____________________________________ Relationship to Child:__________________________
Authorized to Pick Up Child? YES NO
Address (if different from above):____________________________________________________________
Home Phone Number:________________________ Work Phone Number:______________________
Mobile Phone Number:_________________________ Primary Language:________________________
Email Address:____________________________________________________________________________
