CHILD INFORMATION (1)

Child's Last Name (1) *

Child's First Name (1) *

Name you wish child to be called at school (1) *

Birthdate (1) xx-xx-xxxx *

Gender (1) *

Male

Female

Allergies/medications/other significant medical information (1)

Date of last DTP vaccination, enter 0s if you chose to not vaccinate (1)

Has your child had group experience? (1)

Yes

Any further information you feel might be helpful in providing a positive experience for your child? (1)

LIST YOUR FIRST AND SECOND CHOICE FOR SESSION TIME

First Session Choice (1) *

M-F 9:00 am - 3:15 pm

M-W-F 9:00 am - 3:15 pm

T-Th 9:00 am - 3:15 pm

M-F 9:00 am - 11:30 am

M-W-F 9:00 am - 11:30 am

T-Th 9:00 am - 11:30 am

M-W-F 12:45 pm - 3:15 pm

Second Session Choice (1) *

M-F 9:00 am - 3:15 pm

M-W-F 9:00 am - 3:15 pm

T-Th 9:00 am - 3:15 pm

M-F 9:00 am - 11:30 am

M-W-F 9:00 am - 11:30 am

T-Th 9:00 am - 11:30 am

M-W-F 12:45 pm - 3:15 pm

CHILD INFORMATION (2)

Child's Last Name (2)

Child's First Name (2)

Name you wish child to be called at school (2)

Birthdate (2) xx-xx-xxxx

Gender (2)

Male

Female

Allergies/medications/other significant medical information (2)

Date of last DTP vaccination, enter 0s if you chose to not vaccinate (2)

Has your child had group experience? (2)

Yes

Any further information you feel might be helpful in providing a positive experience for your child? (2)

First Session Choice (2)

M-F 9:00 am - 3:15 pm

M-W-F 9:00 am - 3:15 pm

T-Th 9:00 am - 3:15 pm

M-F 9:00 am - 11:30 am

M-W-F 9:00 am - 11:30 am

T-Th 9:00 am - 11:30 am

M-W-F 12:45 pm - 3:15 pm

Second Session Choice (2)

M-F 9:00 am - 3:15 pm

M-W-F 9:00 am - 3:15 pm

T-Th 9:00 am - 3:15 pm

M-F 9:00 am - 11:30 am

M-W-F 9:00 am - 11:30 am

T-Th 9:00 am - 11:30 am

M-W-F 12:45 pm - 3:15 pm

PARENT/GUARDIAN INFORMATION

First Name *

Last Name *

Address

City

State

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY PR VI Other

Zip

Primary telephone number to be used during school hours, (xxx) xxx-xxxx format

Cell phone number, (xxx) xxx-xxxx format

Work number (use home number if no business), (xxx) xxx-xxxx format

Home number, (xxx) xxx-xxxx format

Place of business (use home as answer if no business)

Email Address

Alternate email address to receive notifications

Additional Parent/Guardian First Name

Additional Parent/Guardian Last Name

If different, address for additional parent/guardian

City

State

Zip

Additional parent/guardian primary telephone number to be used during school hours, (xxx) xxx-xxxx format

Additional parent/guardian cell phone number, (xxx) xxx-xxxx format

Additional parent/guardian work number (use home number if no business), (xxx) xxx-xxxx format

If different, additional parent/guardian home number, (xxx) xxx-xxxx format

Additional parent/guardian place of business (use home as answer if no business)

Additional parent/guardian email address

Alternate email address for additional parent/guardian to receive notifications

FAMILY INFORMATION

Child(ren) resides with

Both parents

Father

Mother

Other

If other, please explain housing situation and relationships

Younger sibling birthdate (one) xx-xx-xxxx

Younger sibling birthdate (two) xx-xx-xxxx

Primary language used in home

Home church

How did you hear about CDLC?

MEDICAL/EMERGENCY INFORMATION

Medical Physician's Name for child(ren)

Physician's telephone number, (xxx) xxx-xxxx format

Physician's Address

Physician's City, State, Zip

Medical Insurance Provider

Medical Group Number

Dentist's name for child(ren)

Dentist's telephone number, (xxx) xxx-xxxx format

Dentist's address

Dentist's City, State, Zip

Dental Insurance Provider

Dental Insurance Group Number

AUTHORIZATION FOR PICK-UP (other than parent/guardian)

LOCAL Person authorized to pick up child(ren) if parent/guardian cannot be reached (first)

Authorized person (first) phone number, (xxx) xxx-xxxx format

Authorized person (first) address

Authorized person (first) city, state, zip

LOCAL Person authorized to pick up child(ren) if parent/guardian cannot be reached (second)

Authorized person (second) phone number, (xxx) xxx-xxxx format

Authorized person (second) address

Authorized person (second) city, state, zip

Person NOT authorized to take child(ren) home (first)

Person NOT authorized to take child(ren) home (second)

CIVIL RIGHTS INFORMATION

Provision of this information is voluntary. This information will be used to determine whether or not CDLC is complying with applicable provisions of the civil rights laws.

If you do not provide this information, a representative of CDLC is required to identify the racial/ethnic category of your enrolled child.

Check whether your child is

Hispanic or Latino

Not Hispanic or Latino

Check the race of your child (check one or more)

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

REGISTRATION FEE per child (non-refundable) due at time of registration