Registration Form

Child’s Full Name:____________________________________nickname:______________________

Child’s SS#_______________________ Birthdate:_____________________

Addresss________________________________________________________________

City:_________________________State:_____________Zip code:_________________

Home phone:____________________________

Mother’s full Name:__________________________________________

Name of Employer:____________________________work #:____________________

Work address:__________________________________________________________

Cell phone:_________________________

SS#:______________________________

Father’s full Name:__________________________________________

Name of Employer:_____________________________work#:_____________________

Work address:____________________________________________________________

Cell phone:__________________________

SS#:_______________________________

Parent/Guardian with legal custody:

___________________________________________Parents are: Married_____

Divorced_____Separated_____Widowed____Single____

Other household members (brothers,sisters,grandparents)

Emergency Contacts:

Name:_______________________phone#___________________relationship_________

Others who have your permission to pick up child:

Name:_______________________________Name:_____________________________

Medical Permission Form

Sandra Sciacca has my permission to seek and obtain emergency medical/dental surgical treatment as prescribed by a treating physician for my minor child. I give permission for my child to be transported by car or ambulance to an emergency center for treatment.

Full Name of Minor:__________________________

Birth date:_________________

Allergies to med:_____________________________

Special health problems:_______________________

___________________________________________

Regular medication:___________________________

Blood type:________________

Name of regular Dr:___________________________

Name of insurance co:_________________________

Member/policy #:____________________________

Name of policy holder:________________________

Sandra Sciacca shall not be responsible for providing or paying for the child’s health care. I agree that neither I or my child will bring any claims of any kind against Sandra Sciacca as a result of any injuries, expenses or damages that I or my child may suffer in any way related to the use of her facilities, toys, other children, whether such claims are known or unknown or arise in the future.

Parent/ Guardian Signature: Date:

_________________________________ __________________