Child's Information

• Child's Name * First Last

• Grade Level (or age if not yet in school) *
  Nursery 2 & 3 year olds 4 year olds 5 year olds/Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
• Service(s) you expect to attend
  9:00 AM 10:45 AM 9:00 AM & 10:45 AM

  Date of Birth *

  / MM / DD YYYY
• Address
  
  
• List all allergies
  
  
• Other comments regarding the care of your child including developmental issues or special learning needs.
  
  

---

• Parental Information

• Parent or Guardian's Name * First Last

• Primary Phone * (###)###-####
• Secondary Phone (in case of emergency) (###)###-####
• email address *
• Second Adult Authorized to Pickup Child First Last
  
  
  

  Make sure your child's name tag lists all allergies or special needs. In addition, each week remind the teacher of these issues.