REGISTRATION

Welcome to ABC 123 Academy! We invite you to register your child and give them the opportunity to thrive in a nurturing and engaging learning environment. Our dedicated team is here to support your child's growth and development every step of the way. Join us in fostering their curiosity and passion for learning!

Fill Out the Form Below

Child's Name

Name child is known by

Child's Birth Date

Month

Day

Year

Child's Home Address

Name(s) of Parent(s)/Guardian(s)

Cell Telephone Number

Parent(s)/Guardian(s) Address

Mother's Employer

Mother's Employer Address

Mother's Employer Phone Number

Father's Employer

Father's Employer Address

Father's Employer Phone Number

Mother's Email Address

Father's Email Address

List any other phone numbers that you can be reached at

Instructions regarding how parent/guardian may be reached in an emergency

Person(s) to be contacted in an emergency if parent(s) or guardian(s) can't be reached:

Contact #1 Name

Contact #1 Relationship to Child

Contact #1 Address

Contact #1 Telephone Number

Contact #2 Name

Contact #2 Relationship to Child

Contact #2 Address

Contact #2 Telephone Number

Contact #3 Name

Contact #3 Relationship to Child

Contact #3 Address

Contact #3 Telephone Number

Child's Physician

Name of child's doctor

Doctor's Address

Doctor's Telephone Number

Emergency Authorization

I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be emailed to us stating what procedure the facility is to follow in an emergency.)

Signature

Date

Month

Day

Year

*FORM NOT VALID WITHOUT SIGNATURE OF CHILD'S PARENT/GUARDIAN

Describe any special needs or instructions for your child below

Person(s) the child may be released to:

Person #1 Name

Person #1 relationship to child

Person #1 Address

Person #2 Name

Person #2 relationship to child

Person #2 Address

Person #3 Name

Person #3 relationship to child

Person #3 Address

Person #4 Name

Person #4 relationship to child

Person #4 Address

Person #5 Name

Person #5 relationship to child

Person #5 Address