REGISTRATION FORM

Registration Date:____________ Mother/Guardian First Name: Address: Occupation: Employed By: Work Address: Email: Home Phone: ( Office Phone: ( Work Hours: ) ) Cell Phone: ( ) M.I. Last Name:

Father/Guardian First Name: Address: Occupation: Employed By: Work Address: Email:

M.I.

Last Name:

Home Phone: ( Office Phone: ( Work Hours:

) ) Cell Phone: ( )

Child Information 1 Child First Name: Name child prefers to be called: Childs Address: Gender: [ ] Male [ ] Female Date of Birth: List any existing medical conditions, medication and/or special attention your child may require?
st

M.I.

Last Name: Grade/Class:

Allergies: Pediatricians Name: Address: Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No 2nd Child First Name: Name child prefers to be called: Childs Address: Gender: [ ] Male [ ] Female Date of Birth: List any existing medical conditions, medication and/or special attention your child may require? M.I. Last Name: Grade/Class: Phone: ( )

Allergies: Pediatricians Name: Address: Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No Phone: ( )

3 Child First Name: Name child prefers to be called: Childs Address: Gender: [ ] Male [ ] Female Date of Birth:

rd

M.I.

Last Name: Grade/Class:

List any existing medical conditions, medication and/or special attention your child may require?

Allergies: Pediatricians Name: Address: Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No Phone: ( )

Emergency Contacts & Authorized Pickup Persons: 1 Contact/Pick Up Name: ___________________________________________ Phone: _________________ Relationship to the Child: __________________________ [ ] Able to pick up all children in the family [ ] Not able to pick up the following children:________________________________________________________ 2nd Contact/Pick Up Name: __________________________________________ Phone: _________________ Relationship to the Child: __________________________ [ ] Able to pick up all children in the family [ ] Not able to pick up the following children:________________________________________________________ 3rd Contact/Pick Up Name: __________________________________________ Phone: _________________ Relationship to the Child: __________________________ [ ] Able to pick up all children in the family [ ] Not able to pick up the following children:________________________________________________________ 4th Contact/Pick Up Name: ___________________________________________ Phone: _________________ Relationship to the Child: __________________________ [ ] Able to pick up all children in the family [ ] Not able to pick up the following children:________________________________________________________
st

Lisa Becker

824 W. Turnpike Ave, Bismarck, ND 58501 701-258-5094

email:lkbecker@msn.com