Registration Form (print)
Registration is not complete until registration fee has been received
Child’s Full Name: _______________________________ Birth Date: _________________
Address: _________________________________ Home Phone: _( )___________________
City: ____________________________________ State: _____Zip Code: _________________
Nickname: _______________________________
Mother’s or Guardian’s Full Name: _______________________ Home Phone: ( )____________________
Email Address_________________________ Address: _________________________________
City: ____________________________________ State: _____Zip Code: _________________
Occupation: ____________________________ Work Phone: ( )______________ext._______
Name of Employer: ______________________ Pager or Cellular Phone: ( )_______________
Business Address: _______________________ City: __________________________________
Work Hours: ___________________________
Father’s Full Name: _______________________ Home Phone: ( )____________________
Email Address _____________________________ Address: ________________________________
City: ___________________________________ State: _____ Zip Code: ________________
Occupation: ____________________________ Work Phone: ( )______________ext.______
Name of Employer: ______________________ Pager or Cellular Phone:__________________
Business Address: _______________________ City: _________________________________
Work Hours: ___________________________
Other Household Members:
Names: __________________________________ Ages: _________ Relationships ________________
____________________________________________________________________________________
_____________________________________________________________________________________
Emergency Contacts
(Within 20 mile radius of daycare other than parent or guardian)
Primary Emergency Contact (other than parents or guardian) ____________________________________
Home Phone: __________________________________ Work Phone: __________________________
Relationship to Child: ___________________________________________________________________
Address:______________________________________________________________________________
Secondary Emergency Contact (other than parents or guardian) ____________________________________
Home Phone: __________________________________ Work Phone: __________________________
Relationship to Child: ___________________________________________________________________
Address:______________________________________________________________________________
Person (s) authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name: __________________________________ Comment ______________________________________
_______________________________________________________________________________________
_________________________________________________________________________________________
Kid Code: __________________________ (Secret word between parent & child for identification and pick up)
Person (s) NOT authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
Name: __________________________________ Comment ______________________________________
______________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Emergency Release
Consent to Emergency First Aid & Transportation:
I hereby give permission that my child, _________________________, may be given emergency treatment by a
staff member at Camp Discovery, Mt Calvary Holy Church or Genesis Preschool. I also give permission for my child
to be transported by car, ambulance, or Aid car to an emergency center for treatment, and agree to hold
Camp Discovery, Mt Calvary Holy Church and Genesis Preschool and its employees harmless.
Parent’s Signature _________________________________________ Date: __________________________
Consent to Medical Care and Treatment:
In the event that I cannot be contacted immediately, medical of surgical treatment can be administered to my child
in the case of an accident or emergency, as prescribed by a treating physician, and hold Camp Discovery, Mt
Calvary Holy Church, Genesis Preschool and its employees harmless.
Parent’s Signature _________________________________________ Date: __________________________
Emergency Information
1. Child’s Physician: ________________________________ Phone: ( )_____________________________
2. Preferred Hospital: ________________________________ Phone: ( )____________________________
3. Insurance Company: ______________________________ Policy #: _______________________________
4. Regular Medications: _____________________________________________________________________
5. Blood Type: ____________________________________________________________________________
6. Medicine allergic to: _______________________________________________________________________
7. Food Allergies: ___________________________________________________________________________
8. Any other Allergies: ______________________________________________________________________
9. Any special health conditions: _______________________________________________________________
Field Trip Permission
I hereby request that my child, ______________________________________, be permitted to participate in field
trips, to the park, or any other activities that would involve taking the child outside of the daycare/summer camo for
his/her benefit in attendance at this facility.
Parent’s Signature: ______________________________________________ Date: ____________________
Liability Waiver
It is the intention of ____________________ parent/guardian of ______________________ by this agreement to
exempt and relieve Camp Discovery, Mt Calvary Holy Church, or Genesis Preschool and it's officers, agents,
servants or employees from liability for personal injury, property damage or wrongful death of said minor.
Parent Signature:_______________________________________ Date ______________________
Tuition is due on Monday, the beginning of each week. Monday is the only day that checks are
accepted. There is a $10 per day late fee. All late tuition must be paid in cash.
I understand this is a legally binding contract, and I have read it and understand it.
Persons signing contract are responsible for payment:
Parent/Guardian (Mother) ________________________ Parent/Guardian (Father)______________________
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