The Chalkboard Inc.

Name of Child*
 

Birthday*

 

Sex* —MaleFemale

Address*

Please choose registration season Fall/Spring Summer

Time of day AM PM

Program* Monday Tuesday Wednesday Thursday Friday

Parents(s) or Other Person(s) Placing the Child

Name*

 

Relation to Child*

 

Address*

E-Mail*

 

Phone Number*

 

Mobile Number

 

Pager

 

Place of Employment*

 

Address*

Phone Number*

 

Working Hours*

 

2nd Parent or person Placing the Child

Name

 

Relation to Child

 

Address

E-Mail

 

Phone Number

 

Mobile Number

 

Pager

 

Place of Employment

 

Address

Phone Number

 

Working Hours

 

Other Person to Notify if Person Placing the Child Cannot Be Reached

Name*

 

Phone Number*

 

Address*

Relation to Child*

 

Name*

 

Phone Number*

 

Address*

Relation to Child*

 

Physician to Call if Child Becomes Ill or Injured

Name*

 

Phone Number*

 

Address*

Hospital or Clinic*

 

Name of Person(s) who can take the child home other than Parent*

 

Child Information

Medical Problems

Physical Handicaps

Restrictions for Play

Allergies

Food Likes

Food dislikes

Fears

Brothers and Sisters

Other Programs Attended

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