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Parents: Registration

Person(s) designated by guardian to whom child may be released:

Family Information

Child Lives With ...

Guardians are ...

Guardian(s)

1	Guardian's First Name Guardian's Last Name Relationship to Child Home Address Street Address Address Line 2 City State Zip Code Home Phone Mobile Phone Text messages may be used to notify guardians of emergency closings, etc. Please provide your mobile number and carrier for each guardian's phone. Mobile Carrier Email Address Business Business Name Business Phone Street Address Address Line 2 City State Zip Code
2	Guardian's First Name Guardian's Last Name Relationship to Child Home Address Street Address Address Line 2 City State Zip Code Home Phone Mobile Phone Text messages may be used to notify guardians of emergency closings, etc. Please provide your mobile number and carrier for each guardian's phone. Mobile Carrier Email Address Business Business Name Business Phone Street Address Address Line 2 City State Zip Code
1	Guardian's First Name Guardian's Last Name Relationship to Child Home Address Street Address Address Line 2 City State Zip Code Home Phone Mobile Phone Text messages may be used to notify guardians of emergency closings, etc. Please provide your mobile number and carrier for each guardian's phone. Mobile Carrier Email Address Business Business Name Business Phone Street Address Address Line 2 City State Zip Code

Emergency Contacts

1	First Name Last Name Phone # while child is in care
2	First Name Last Name Phone # while child is in care
3	First Name Last Name Phone # while child is in care
1	First Name Last Name Phone # while child is in care

Person(s) to whom child may be released

Please enter person(s) OTHER than a parent/guardian with whom child may be released.

1	First Name Last Name Street Address Address Line 2 City State Zip Code Phone # while child is in care
2	First Name Last Name Street Address Address Line 2 City State Zip Code Phone # while child is in care
3	First Name Last Name Street Address Address Line 2 City State Zip Code Phone # while child is in care
1	First Name Last Name Street Address Address Line 2 City State Zip Code Phone # while child is in care