Registration Form - wgm-daycare

Child Information

Full Name:

This field is required.

Date of Birth:

This field is required.

Gender

This field is required.

Address

Address Line 1

This field is required.

Address Line 2

This field is required.

City

This field is required.

State

This field is required.

Postal Code

This field is required.

Country

This field is required.

Parent/Guardian Information

Parent/Guardian 1

Full Name:

This field is required.

Relationship to Child:

This field is required.

Phone Number:

This field is required.

Email:

This field is required.

Home Address

Address Line 1

This field is required.

Address Line 2

This field is required.

City

This field is required.

State

This field is required.

Postal Code

This field is required.

Country

This field is required.

Parent/Guardian 2

Full Name:

This field is required.

Relationship to Child:

This field is required.

Phone Number

This field is required.

Email

This field is required.

Home Address

Address Line 1

This field is required.

Address Line 2

This field is required.

City

This field is required.

State

This field is required.

Postal Code

This field is required.

Country

Emergency Contacts (Other than Parents)
Full Name:

This field is required.

Phone Number

This field is required.

Relationship:

This field is required.

Authorized Pick-Up Persons

(Individuals allowed to pick up your child besides parents/guardians).
• Must show photo ID.

Full Name:

This field is required.

Phone Number

This field is required.

Relationship

This field is required.

Program Enrollment

Start Date:

This field is required.

Program

This field is required.

Schedule

This field is required.

Medical Information

Child’s Physician:

This field is required.

Phone Number

This field is required.

Preferred Hospital:

This field is required.

Allergies:

This field is required.

Special Needs/Conditions:

This field is required.

Medications Taken Regularly:

This field is required.

I authorize Wiggles & Giggles Montessori Daycare staff to obtain emergency medical treatment for my child if necessary.

This field is required.

I agree to follow all daycare policies and pay tuition as outlined in the Parent Handbook. for my child if necessary.

This field is required.

I have provided accurate and up-to-date information.

This field is required.

I give permission for Wiggles & Giggles Montessori Daycare to take photos/videos of my child for updates and communication.

I do not give permission for my child to be photographed/recorded.

Parent/Guardian Signature:

Print your name

This field is required.

Date of signature:

This field is required.