Registration Form

Ms. Candace’s Childcare Registration Form

Child’s Name: ___________________________________________     Nickname __________________

Child’s Age: _______________________ Sex: _________________ Birth Date: _________________

Mother/Guardian’s Name: _____________________________________________________________

Home Phone: _________________________________________________________________________

Home Address: ________________________________________________________________________

Occupation/ Workplace: _________________________________________________________________

Work Phone: __________________________________________________________________________

Email Address: ________________________________________________________________________

Father/Guardian’s Name: _____________________________________________________________

Home Phone: _________________________________________________________________________

Home Address: ________________________________________________________________________

Occupation/ Workplace: _________________________________________________________________

Work Phone: __________________________________________________________________________

Email Address: ________________________________________________________________________

Parents are (Check all that apply)

Living Together _______ Separated ______ Divorced _______ Widowed _______

Name(s) of siblings or other family in the home: ______________________________________________

Days Desired (Check all that apply)

M ______ T _____ W _____   Th _____ F _____

Office Use Only:

Reg Paid: Cash ______   PayPal ______ Check ______ Check # ______   Date Payment was received: ________________________

Discounts applied to tuition fee: __________________    Date child was enrolled: ________________   Providers Initials: __________