Child's Name:_____________________________SSN#_______________Date Enrolled:__________

Home Address:____________________________Home Phone:______________________________

City:____________________State:_______________Zip:__________Sex:______Birthdate:_______

Father's Name:_______________________________Home Phone:___________________________

Father's Address (If different):_______________City:___________State:___________Zip:________

Place of Employment and Address:__________________________Business Phone_____________

Mother's Name:_______________________________Home Phone:___________________________

Mother's Address (If different):_______________City:___________State:___________Zip:________

Place of Employment and Address:__________________________Business Phone_____________

Marital Status:_____________________________Who Has Custody of Child?_________________

SSN# of Father:____________________________SSN# of Mother:___________________________

Name, Address of Two Emergency Contact Persons:

Name:_______________________Address:_________________City:___________Phone:_________

Name:_______________________Address:_________________City:___________Phone:_________

Name, Address and Telephone of Person(s) To Whom Child Can Be Released:_______

Name:_______________________Address:_________________City:___________Phone:_________

Name:_______________________Address:_________________City:___________Phone:_________

Name:_______________________Address:_________________City:___________Phone:_________

Please be sure Emergency Contact and Released to Persons are willing to pick up child, if you cannot be reached.