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