Childs Name *

First Name

Last Name

Child's Street Address *

Place of Primary Residence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Date of Birth *

MM

DD

YYYY

Primary Parent Contact *

First Name

Last Name

Primary Parent Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Parent (Primary Phone) *

(###)

###

####

Primary Parent (Secondary Phone)

(###)

###

####

Primary Parent (Work Phone) *

(###)

###

####

Secondary Parent Name *

First Name

Last Name

Secondary Parent Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Parent (Primary Phone) *

(###)

###

####

Secondary Parent (Secondary Phone) *

(###)

###

####

Secondary Parent (Work Phone) *

(###)

###

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Is there someone that is not allowed to pick up your child? *

Yes

No

If Yes, Please provide their Full Name

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Family Physician Name *

First Name

Last Name

Family Physician Phone

(###)

###

####

Family Physician Work Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child require medication that must be given daily? *

Yes

No

Are your child's immunizations up-to-date? *

Yes

No

I consent to the administration of health care by the staff of the Westend Community Playschool. Ifemergency assistance is required, I understand the medical professionals will decide where medicalassistance will be sought. I acknowledge that I will be responsible for the cost of ambulance services, ifany *

Yes

No