FORM
Child Information Form
Childs Name: ________________________________________ Primary Language: ________________________
Childs Address: ______________________________________________________________________________
Street City/Town Zip Code
Place of Birth: _____________________________________________________Date of Birth: _____/_____/_____
Childs Schedule: MON __________ TUE __________ WED __________ THU __________ FRI ___________
Parent/Guardian Information
Name:____________________________________ Name: ________________________________________
Relationship: ______________________________ Relationship: __________________________________
Address: _________________________________ Address: ______________________________________
_________________________________________ ______________________________________________
Home E-mail Address: ______________________ Home E-mail Address: ___________________________
Cell Phone: _______________________________ Cell Phone: ____________________________________
Home Phone: ______________________________ Home Phone: __________________________________
Others in Family Relationship: ____________________________________________________________________
Parent/Guardian Business Information
Company Name: ___________________________ Company Name: ________________________________
Address: _________________________________ Address: ______________________________________
_________________________________________ ______________________________________________
Business Phone: __________________________ Business Phone: _______________________________
E-mail Address: ___________________________ E-mail Address: _________________________________
Medical Information
Eye Color: ______ Hair Color: _______ Height: ______ Weight: ______ Race: ______ Gender M F
Identified Allergies: ____________________________________________________________________________
Identifying Marks: ____________________________________________________________________________
Health Insurance Provider: _____________________________________________________________________
Physician/Dentist Information
Name of Physician/Clinic: ______________________________________ Phone: ________________________
Physician Address: ___________________________________________________________________________
Street City/Town Zip Code
Date of Childs Last Physical (WA State Only): ______________________________________________________
Name of Dentist: _____________________________________________ Phone: ________________________
Dentist Address: _____________________________________________________________________________
Street City/Town Zip Code
Parent/Guardian Signature: _____________________________________ Date: _________________________
FOR CENTER USE: Center: _________________________ Date of Admission________________ Age of Admission: _______________
Date Registration Fee Recd:_________________________ Directors Initials: _________________
Child Information Form: Operations Page 1 of 1
Effective: 06/2015
