Registration Form

Contact Information
Child's Full Name:*
Child's Nickname:*
Birthdate:
Date of Enrolment:
Home Phone:
Address:
Mother's Information
Mother's Full Name:
Mother's Home Phone:
Mother's Address:
Mother's Employer
Mother's Employer:
Mother's Occupation:
Hours at Work:
Days at Work:
Work Phone:
Cell Phone:
Employer's Address:
Untitled
Father's Information
Father's Full Name:
Father's Home Phone:
Father's Address:
Father's Employer
Father's Employer:
Father's Occupation:
Hours at Work:
Days at Work:
Work Phone:
Cell Phone:
Employer's Address:
Fill out only if applicable
Parent/Guardian with legal custody:
Do you have a decree on file?:
Parents are:
Primary Emergency Contact
Full Name:
Relationship to child:
Address:
Phone:
Secondary Emergency Contact
Full Name:
Relationship to child:
Address:
Phone:
Person(s) authorized to pick up my child (Besides parents/guardians or emergency contacts)
Person #1:
Person #2:
Person #1:
Daycare references
Has your child ever been in daycare before?:
If so, why did you leave?:
Name of previous provider:
Phone number of previous provider:
Consent to Emergency First Aid & Transportation
I hereby give my permission that my child, may be given emergency treatment by Creative All Stars Childcare I also give permission for my child to be transported by car or ambulance to an emergency center for treatment.
- yes
- no
Consent to Medical Care & Treatment
In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician.
- yes
- no
Consent to Photograph
Consent to Photograph
- yes
- no
Creative All Stars Childcare will not be responsible for paying for my child's healthcare
Child's Physician:
Phone:
Preferred Hospital:
Phone:
Insurance Company:
Policy Number:
Regular Medications:
Blood Type:
Medicine Allergic to
Food Allergies:
Other Allergies:
Special Health Conditions:
Carecard Number:
Creative All Stars Childcare will not be responsible for paying for my child's healthcare
Number of days per week childcare is needed:
Days of week care is needed:
What time will you bring your child to daycare?:
What time will you pick-up your child?:
For Out of School Care
What School does your child attend?
Email*
Comments
Agreement
I understand that this is a legally binding document, and have read it and understand it.
- yes
- no

Registration Form

Contact Information

Mother's Information

Mother's Employer

Father's Information

Father's Employer

Fill out only if applicable

Primary Emergency Contact

Secondary Emergency Contact

Person(s) authorized to pick up my child (Besides parents/guardians or emergency contacts)

Daycare references

Consent to Emergency First Aid & Transportation

Consent to Medical Care & Treatment

Consent to Photograph

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

Creative All Stars Childcare will not be responsible for paying for my child's healthcare

For Out of School Care

Agreement