Registration

Enrollment Date(Required)

Name of Child(Required)

Birth date(Required)

Address(Required)

Street Address City State ZIP Code

How did you hear about us?(Required)

Phone Identification Code Word

Father

Business Phone#

Employment

E-mail address

Cell Phone #

Soc. Security #

Mother

Business Phone#

Employment

E-mail address

Cell Phone #

Soc. Security #

Marital status of parents?(Required)

Who is the child's legal guardian?.(Required)

Who is responsible for paying tuition fees?(Required)

Check the days your child will be attending:(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Arrival Time:

Pick-up Time:

Check the program your child will be enrolled in:

Infant/Toddler Care

Two Year Old Care

3-5 Year Old Full-Day

Kindergarten

Preschool (Mornings only)

Summer Camp

School-age

Full days when school is out of session?

Yes

From

Race:

White

American Indian or Alaskan Native

Black or African American

Asian

Pacific Islander

Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Emergency Contacts:

I Authorize the following persons as a person who may be called in an emergency or illness and are authorized to come and pick up this child without prior approval from custodial parents (I.D. REQUIRED.
*** Pease include one out of area contact***

Name(Required)

Address(Required)

Street Address City State ZIP Code

(Full address is required by Child Care Licensing)

Relationship to child(Required)

Phone(Required)

Name

Address

Street Address City State ZIP Code

(Full address is required by Child Care Licensing)

Relationship to child

Phone

Name

Address

Street Address City State ZIP Code

(Full address is required by Child Care Licensing)

Relationship to child

Phone

Name

Address

Street Address City State ZIP Code

(Full address is required by Child Care Licensing)

Relationship to child

Phone

Business Name or Person

Reason

BY SIGNING BELOW, YOU ACKNOWLEDGE AND AGREE A FOLLOWS:

I understand and agree to the above statements

Parent/guardian signature(Required)

Date(Required)

Director's signature.(Required)

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Emergency Contacts:

BY SIGNING BELOW, YOU ACKNOWLEDGE AND AGREE A FOLLOWS:

I understand and agree to the above statements

Ogden Center

South Ogden Center

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Ogden Center

South Ogden Center

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