Child Care Registration Form
CHILD’S INFORMATION
Child’s Full Name: ______Birth Date: _____/_____/_____
Address: ______Home Phone: ______
City: ______State: ______PC/Zip Code: ______
Nickname: ______
PARENT/GUARDIAN INFORMATION
Mother’s Full Name: ______Home Phone: ______
Address: ______
City: ______State: ______PC/Zip Code: ______
Occupation: ______Work Phone: ______ext.______
Name of Employer______Pager or Cellular Phone: ______
Business Address: ______City: ______
Work Hours: ______Driver’s License # ______
Father’s Full Name: ______Home Phone: ______
Address: ______
City: ______State: ______PC/Zip Code: ______
Occupation: ______Work Phone: ______ext.______
Name of Employer______Pager or Cellular Phone: ______
Business Address: ______City: ______
Work Hours: ______Driver’s License # ______
Parent/Guardian with legal custody ______
Parents are: Married ___ Living Together___ Divorced ___ Separated ___ Widowed ___ Single ___
Other Household Members:
Names: ______Ages: ______Relationships ______
Names: ______Ages: ______Relationships ______
Names: ______Ages: ______Relationships ______
CHILD PICK-UP INFORMATION
Please list below the people who have *Permission* to pick up your child.
*Note: Anyone picking up your child must have picture ID.
Name: ______Phone: ______Relationship: ______
Name: ______Phone: ______Relationship: ______Name: ______Phone: ______Relationship: ______
Please list those persons who *Do Not Have Permission* to pick up your child.
Please explain the reason below or talk to your caregiver so she is aware of the situation.
Name: ______Phone: ______Relationship: ______
Name: ______Phone: ______Relationship: ______
Reason person is not allowed to pick up your child:
Name: ______
Reason: ______
Name: ______
Reason: ______
EMERGENCY CONTACTS
Primary Emergency Contact (other than parents or guardian)
Name: ______
Home Phone: ______Work Phone: ______
Relationship to Child: ______
Address: ______
Secondary Emergency Contact (other than parents or guardian) Name: ______
Home Phone: ______Work Phone: ______
Relationship to Child: ______
Address: ______
Any Special Instructions on how to reach parents: ______
______
EMERGENCY INFORMATION
1. Child’s Physician: ______Phone: ______
2. Preferred Hospital: ______Phone: ______
3. Child’s Dentist: ______Phone: ______
3. Insurance Company: ______Policy #: ______
4. Regular Medications: ______
5. Blood Type: ______
6. Medicine allergic to: ______
7. Food Allergies: ______
8. Any other Allergies: ______
9. Immunization Record: Date of Last Immunization: ______
10. Any special health conditions: ______
11. Child has had:Child suffers from:
[ ] Measles[ ] Headaches
[ ] German Measles[ ] Earaches
[ ] Chicken Pox[ ] Sore Throat
[ ] Mumps[ ] Stomach Aches
[ ] Whopping Cough[ ] Flu / Colds
[ ] Other ______[ ] Other ______
Child # 1
IMMUNIZATION RECORD
DPT1. ___/___/___ 2. ___/___/___ 3. ___/___/___ 4. ___/___/___ 5. ___/___/___
Polio1. ___/___/___ 2. ___/___/___ 3. ___/___/___ 4. ___/___/___ 5. ___/___/___
MMR ___/___/___Measles ___/___/___ Mumps ___/___/___
Rubella ___/___/___ TB ___/___/___ HIV ___/___/___ HIB ___/___/___
Child # 2
IMMUNIZATION RECORD
DPT1. ___/___/___ 2. ___/___/___ 3. ___/___/___ 4. ___/___/___ 5. ___/___/___
Polio1. ___/___/___ 2. ___/___/___ 3. ___/___/___ 4. ___/___/___ 5. ___/___/___
MMR ___/___/___Measles ___/___/___ Mumps ___/___/___
Rubella ___/___/___ TB ___/___/___ HIV ___/___/___ HIB ___/___/___
OTHER IMPORTANT INFORMATION/PROVISIONS
Child will need special provisions such as:
[ ] Extra curricular activity [ ] Yes [ ] No
If yes, please give details: (what activity, when, if transportation is required, specific arrangements to attend with other family members/friends, etc.)
______
______
[ ] Other provisions we should be aware of: ______
______
______
Do you have any outstanding concerns? ______
BusyBee Childcare 31 East 11th Ave
RunnemedeNJ08078
856-939-0533