Parent/Guardian Information

First Name

Last Name

Relationship to Child

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Child's Name

First Name

Last Name

Date of Birth

YYYY

Gender

Emergency Contact Information

First Name

Last Name

Relationship to Child

Primary Phone Number

(###)

###

####

Medical Information

Pediatrician's Information

First Name

Last Name

Pediatrician's Phone Number

(###)

###

####

Does your child have any allergies?

Does your child have any medical conditions or require any medications?

Authorized Pick-Up Persons

(List any additional individuals authorized to pick up your child. Please provide full name, and contact number.)

When would you like your child to start?

YYYY

How did you hear about us?

Consent & Agreement

I, the undersigned, give permission for my child to participate in the daycare program and authorize the staff to administer necessary first aid and seek emergency medical treatment when needed. While every precaution is taken to ensure a safe environment, I understand that unforeseen incidents may occur. In enrolling my child, I assume these risks and release the daycare from liability for any injuries or accidents.

I confirm that the information provided is accurate and complete

Pictures Consent

I consent to the use of photographs and videos of my child taken during the program for promotional and archival purposes.

Anything else you’d like to share or ask?

Registration form

Karaz Kidz