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PLEASE NOTE: Submitting this registration form certifies that you have read and understand the policies at Great Beginnings Child Care and agree to these policies, as outlined in the Parents Handbook.

Your Email Address: Date of Registration:     Child’s Surname: (required) Child’s Given Name(s): (required)     Child’s Home Address: (required)       Child’s Home Phone: (required) Child’s Birth Date: (required)           Mother’s Name: (required) Mother’s Home Phone: (if different from child’s)     Mother’s Home Address: (if different from child’s)       Mother’s Work Address: Mother’s Work Phone:         Father’s Name: (required) Father’s Home Phone: (if different from child’s)     Father’s Home Address: (if different from child’s)       Father’s Work Address: Father’s Work Phone:         CHILD’S HEALTH CARD NUMBER: (required)     PERSON TO BE CALLED OTHER THAN PARENTS IN THE CASE OF AN EMERGENCY:   Emergency Contact Name: (required) Emergency Contact Phone: (required)     Emergency Contact Address: (required)     CHILD’S DOCTOR:   Doctor Name: (required) Doctor Phone: (required)     Doctor Address:       Child’s Interests:       Child’s Dislikes:       Additional Comments:       Special Instructions:       I give permission for my child to take part in outings and excursions as may be arranged from time to time.  I understand that some trips may include vehicular transportation. In the event that a trip will be planned requiring vehicular transportation, parents will be notified.   I have read and understand the policies at Great Beginnings Child Care and I agree to these policies.   Your name: (required) Today’s Date: (required)     Child’s Start Date: (required) Child’s Withdrawal Date: (if applicable)

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