Child's Name ____________________ Sex _____ Birth date ____________Enrollment Date __________

Home Address __________________________________Zip Code _________ Telephone ___________

Marital Status of Parents (as applicable) ____________________________________________________

Mother or Guardian's Name __________________________________Social Sec. # ________________

Business Address __________________________________________Business Telephone ___________

Employer ________________________________________________Cellular or Pager _____________

Father or Guardian's Name __________________________________Social Sec. # ________________

Business Address _________________________________________Business Telephone ___________

Employer _______________________________________________Cellular or Pager ______________

Persons who may be called in case of illness or emergency if neither parent or guardian can be reached:

Name Relationship Address Telephone

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Emergency out of state contact __________________________________________________________

Persons designated to pick up child:

Name Address Telephone

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Child's Physician _____________________________________________________________________

Name Address Telephone

Child's Dentist ______________________________________________________________________

Name Address Telephone

Describe any pertinent social information or special needs of the child. _____________________________

__________________________________________________________________________________

__________________________________________________________________________________

Give instructions for the care of the above mentioned problems or conditions ________________________

__________________________________________________________________________________

__________________________________________________________________________________

We (I) _______________________, authorize employees of Children's Corner Preschool and Child Care

Center to administer first aid as may be appropriate in your sole discretion, to arrange for transportation, and

to give any consent required by the emergency facility or hospital in my stead as parent that may be required

in the event my child or children are injured.

As parents or legal guardian, I understand that the above named child will periodically leave the school grounds

to participate in field trips and other activities. I hereby give my consent that the above named child may attend

and participate in such activities and I further release Children's Corner Preschool and Child Care Center, its

officers, employees and volunteers from any and all claims or liability of any nature whatsoever for injuries,

accidents or damage of any nature whatsoever sustained by said child while participating in these activities, I

also give my consent to Children's Corner to provide emergency transportation in case of evacuation or

relocation.

____________________________________________________ _________________

SIGNATURE OF PARENT OR GUARDIAN DATE

____________________________________________________ _________________

SIGNATURE OF PARENT OR GUARDIAN DATE