Market Street UMC Learning Center
2009-10 REGISTRATION FORM
_______ Check No# for supplies fee _______ Bill account
for supply fee
___ one charge ____ 3 installments
Child _____________________________________________
Birth Date ______________ Sex ________
Address ____________________________________________________
Home Phone ______________
Chronic Physical
Problems/Pertinent Developmental Information/Special Accommodations Needed
_____________________________________________________________________________________
Previous Child Care
Programs/Schools Attended
______________________________________________________________________________________
If child attends
this Center and another school/program, give name of school/program
_____________________________________________________________________________________
Father ______________________ Place Employed ________________________
Phone ______________
Home Address ________________________________________________
Home Phone ______________
Mother ______________________ Place
Employed ________________________
Phone _____________
Home Address ________________________________________________
Home Phone
______________
Person(s) or Agency
having Legal Custody of Child ____________________________________________
Home Address
________________________________________________
Home Phone ______________
Business Address
______________________________________________
Phone ___________________
EMERGENCY INFROMATION
Allergies or intolerance
to food, medication, etc., and action to take in an emergency
_____________________________________________________________________________________
Child’s Physician
_______________________________________________
Phone __________________
Names and Addresses
of Two People to Contact if Parents Cannot be Reached
__________________________________________________________________
Phone _____________
__________________________________________________________________
Phone _____________
Persons Authorized
to Pick Up Child _______________________________________________________
_____________________________________________________________________________________
Persons NOT Authorized
to Pick Up Child ________________________________________
