Childs Name

First Name

Last Name

Birthdate

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Cell Phone

(###)

###

####

Registering For

Please Check All That Apply

Fall M/W

Fall Tu/Th

Spring M/W

Spring Tu/TH

Summer

Parent/Guardian

First Name

Last Name

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Occupation

Employer

Parent/Guarden

First Name

Last Name

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Occupation

Employer

Family Situations

Are there any family situations that the CDO staff/teachers need to be aware of (separation, divorce,illness, death, adoption, custody issues, fears)?

Food Allergies

Please list any food/drink allergies and what measures need to be taken to keep your child safe.

Medical Concerns

Are there any other medical concerns teachers need to know about?

Family Church Affiliation

Childs Physician

Physician's Phone

(###)

###

####

Emergency Contact

Emergency contact in case a parent cannot be reached.

Relationship

Emergency Contact Phone

(###)

###

####

Authorized to Pick Up?

Yes

WHo Else Is Authorized to Pick Up Your Child?

First Name

Last Name

Relationship

Phone

(###)

###

####

Who Else Is Authorized to Pick Up Your Child?

First Name

Last Name

Relationship

Phone

(###)

###

####

WhO Else Is Authorized to Pick Up Your Child?

First Name

Last Name

Relationship

Phone

(###)

###

####

LITTLE LIGHTS REGISTRATION

LITTLE LIGHTS REGISTRATION

LITTLE LIGHTS REGISTRATION LITTLE LIGHTS REGISTRATION

LITTLE LIGHTS REGISTRATION