TODDLER REGISTRATION FORM

TODDLER REGISTRATION FORM
1477 South Schodack Rd. Castleton, NY 12033 (518)477-7103
CHILD INFORMATION:
Name
Nick nameLast Name
First Name:
Telephone:
Start Date:
MonthDayYear
Date
My child will attend: (Please Circle Session)
Session I: Two DaySession II: Three DaySession III: Five Day
Timings: (Please Circle Timing)
Before Care: 7:00AM-9:00AM After Care:11:30AM-5:30PM
Classroom:
Apt.
Street
State:
State:
Zip:
City
Date of Last Medical Exam:
MonthDayYear
Date
Allergies: (Please be specific):
Pediatrician:
Developmental Concerns:
PARENT INFORMATION:
Last Name:
Before Care: 7:00AM-9:00AM After Care:11:30AM-5:30PMFirst Name:Full Day: 9:00AM-11:30AM
Name
First NameLast Name
Cell Phone
Name
First NameLast Name
Cell Phone
EMERGENCY INFORMATION:
Relationship to Child
Telephone
Parents Signature:
Should be Empty: