|
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.
|