Child's Name:

Nickname:

Birthdate:

Current Age:

Sex:  M:F:

Address:

City:

State:

Zip:

Check one:  Full day Program:Half day program:

Enrolling for:  Infants:Ones:Two:Two ½:Threes:Fours:VPK:

After school:

Name of elementary school:

Adventure Camp:

Days of the week in Care:  M:T:W:TH:F:

FAMILY INFORMATION:   Child lives with:  Mother:Father:Both:Guardian:

Mother's Name:
Mother's Email Address:
Mother's D.L. #
Address

Employer:
Employer Address:

Father's Name:
Father's Email Address:
Father's D.L. #
Address

Employer:
Employer Address:

MEDICAL INFORMATION:

I hereby grant permission for the staff of Nob Hill Academy to contact the following medical personnel to obtain emergency medical care if warranted:

Doctor:

Address:

Phone #:

Doctor:

Address:

Phone #:

Hospital Preference: 1.

2.

Does your child have any allergies:  Yes:No:

List allergies:

Does your child take any medication:  Yes:No:

List Medication:

Please list, special medical or dietary needs, or other areas of concern:

Emergency contact other than a parent: Name:

Phone:

CONTACT:

My child may be released only to the custodial parents or legal guardian and the persons listed below. The following people can also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason the custodial parent or legal guardian cannot be reached:

Name:

Home:

Cell:

Relationship to Child:

Name:

Home:

Cell:

Relationship to Child:

Name:

Home:

Cell:

Relationship to Child:

Name:

Home:

Cell:

Relationship to Child: