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Before and Afterschool Care Registration

A registration form for before- and after-school care programs that gathers student details, parent or guardian information, medical history, and authorized pick-up contacts.

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Enrollment Details

Expected Start Date

Expected Departure Date

School Attending

Grade Attending

When do you need care?

Which class are you wanting to register for?*

What days of the week are you looking for care?*

First Name*

Last Name*

Gender*

Male Female

Birth Date*

Home Phone*

Address*

Dirección

Ciudad

Estado / Provincia

Código postal

Health Care #*

Doctor's Name*

Nombre

Apellido

Doctor's Phone Number*

Full Name*

Nombre

Apellido

Home*

Cell

Work

E-mail*

Address Same as Child?*

Yes No

Parent/Guardian 2

Parent/Guardian 1 Address

Dirección

Ciudad

Estado / Provincia

Código postal

Full Name

Nombre

Apellido

Home

Cell

Work

E-mail

Address Same as Child's?

Yes No

Additional Address Information

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Would your child like to be in a class with a friend?

Yes No

If yes, name and age of friend(s)?

Is your child immunized?*

Yes No

Does your child have any allergies?*

Yes No

If yes, please list them, including any food or drug allergies.

Does your child have any medical conditions?

Does your child require any medication? If yes, please list these medications.

Do you authorize us to administer the medications listed above?

Yes No

Please list the people authorized to pick up your child.

Does your child have any siblings?*

If yes, what is their age(s)?

Comments

Are you a member of Lil Paw's or a subsidiary of Lil Paws?

If yes, which one?

Full Name*

Nombre

Apellido

Address*

Dirección

Ciudad

Estado / Provincia

Código postal

Home*

Cell

Work

Thank you for completing this registration form.

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