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Registration | Registration – 3 Sisters Academy
Registration
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    Child Care Registration Form

    Todays Date:

    Enrollment Date:

    Child's First Name:

    Child's Middle Name:

    Child's Last Name:

    Child's Legal Guardian:

    Full Name of Mother:

    Mother's Address:

    Mother's Home Phone:

    Mother's Work Phone:

    Mother's Cell Phone:

    Mother's eMail address:

    Mother's Employer:

    full name of father:

    Father's address:

    Father's Home Phone:

    Father's Work Phone:

    Father's Cell Phone:

    Father's eMail address:

    Father's Employer:

    Child's Physician:

    Physician's Phone Number:

    Child's Dentist:

    Dentist's Phone Number:

    Person(s) to contact in case of emergency (other than parent):

    Name:

    Relationship:

    Home Phone:

    Work Phone:

    Name:

    Relationship:

    Home Phone:

    Work Phone:

    Authorized Pickup

    List Person(s) Authorized to pick up child

    Name:
    Phone:

    Name:
    Phone:

    Name:
    Phone:

    Name:
    Phone:

    Name:
    Phone:

    Name:
    Phone:

    Has child had previous experience away from home?
    YesNo

    If so, explain:

    Are your Child’s immunizations up to date?YesNo

    If so, explain:

    Authorized Permission

    Field Trips: ALLOWEDNOT allowed

    Non-Vehicle Excursions: ALLOWEDNOT allowed

    Water Activities: ALLOWEDNOT allowed

    Pool Activities: ALLOWEDNOT allowed

    Sprinkler Activities:
    ALLOWEDNOT allowed

    Child's Health History

    Does child have any known health problems?YesNo

    If so, explain:

    Check any of the following illnesses the child has had:AsthmaEarachesMumpsWhooping CoughBronchitisEczemaPneumoniaPolioChicken PoxFrequent ColdsCroupConvulsionsMeaslesInfluenzaRheumatic FeverDiphtheriaTonsillitis

    Other:

    Please list any injuries child has had:

    Does your child have any known allergies? YesNo

    If yes, explain what they are and the reactions:

    Does your child take any medication on a regular basis?YesNo

    If yes please list the name of the medication(s) and the medical condition for which it is taken:

    Do you have any concerns about your child’s development?
    YesNo

    If yes please comment:

    Please comment on any other medical information/ or special need the child care provider should be aware of:

    I authorize the child care provider/staff to obtain the following services for this child if necessary: Public Health Nurse, Physician and or Ambulance in the event of an emergency. (ambulance fees and/or health care costs are the responsibility of the parent/guardian)

    Type Your Full Name: