2020-21 Registration Form | Creative Care Christian Preschool

2021-22 Enrollment Application

To register your child(ren), please carefully fill out ALL sections of the form below.

If a required field is not applicable for your child, please type N/A.

Child Information

Child First Name

Child Last Name

Child Home City

Child Home Address

Child Home State

Child Home Zip

Date of Birth

Sex

Male

Female

Parent/Guardian Information

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent/Guardian 1 E-mail

Parent/Guardian 1 Cell Phone

Parent/Guardian 1 Work Phone

Parent/Guardian 1 Address

Parent/Guardian 1 City

Parent/Guardian 1 State

Zip Code

Parent/Guardian 1 Driver's License #

Siblings (names/ages):

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 E-mail

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Work Phone

Parent/Guardian 2 Address

Parent/Guardian City

Parent/Guardian 2 State

Zip Code

If divorced, which parent/guardian has legal custody?

May the non-custodial parent pick up the child?

If answer is yes, include release as the Emergency Contact in the section below. If answer is no, documentation from the court may be required.

Emergency and Authorized Pick-Up

Emergency Contact other than parents

Emergency Contact Phone Number

Relationship

Your Child will only be released to the contacts listed on this form and the following persons:

Authorized Pick-up Person 1

Authorized Pick-up Person 1 Phone Number

Relationship

Authorized Pick-up Person 2

Authorized Pick-up Person 2 Phone Number

Relationship

Medical Information

Child's Physician

Physician Address

Physician Phone #

Child's Dentist

Dentist Address

Dentist Phone #

Hospital Preference

Insurance Company

Policy #