Tiny Toes Daycare Registration

Program Options*

Preferred Start Date*

Preferred Start Date - Additional Information

Child's Information

Child's Name*

First Name Last Name

Child's Home Address*

Street Address City Postal Code

Child's Birthdate*

Child's Birthdate

Gender

Mother/Guardian Contact Information

Mother / Guardian Name*

First Name Last Name

Mother / Guardian*

Cell# Work#

Home Address*

Street Address City Postal Code

Mother / Guardian Email*

Email

Father/Guardian Contact Information

Father / Guardian*

First Name Last Name

Father / Guardian*

Cell# Work#

Home Address*

Street Address City Postal Code

Father / Guardian Email*

Email

Parent/Guardian with legal custody*

*If there is a custody order please include a copy with your registration

Emergency Contact Information

Emergency Contact (Cannot be Mother or Father, must have a local address)

Emergency Contact Name*

Name Cell# Work#

Emergency Contact Address*

Street Address City Postal Code

List of people allowed to pick up your child

List anyone allowed to pick up your child outside of mother/father/emergency contact

Medication Required (epi pen, puffer, etc.)?*

Yes
No

Medication Required Type

Relevant Health information (Medical Condition (s))?*

Yes
No

List Medical Condition(s):

Does your child have any pre-existing conditions that may present as influenza like symptoms? Ex: Allergies, chronic cough, etc*

Yes
No

List pre-existing Condition(s):

Is Your Child Immunized?*

Yes
No

Allergies?*

Yes
No

Allergies (please list)

Dietary restrictions (please list)

Does your child have any Developmental/Learning Delays(ie. Diagnosed or suspected ADD/ADHD/ODD/Autism/Delays)*

Yes
No

If yes, please indicate details:*

Does your child require any additional assistance?*

Yes
No

If yes, please indicate details:

Please list any other relevant Information:

Cultural Background:

I agree:*

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Tiny Toes Daycare Registration

Program Registration-Tiny Toes Day Care

Child's Information

Mother/Guardian Contact Information

Father/Guardian Contact Information

Emergency Contact Information