Office use only:
Date Received:________________
Classroom:___________________
Teacher(s):___________________
REGISTRATION FORM

Child's Name:

 Date of Birth:
Parents/Guardians Name: E-Mail Address:

Address:

 

Mailing Address:

 
Parents/Guardians Phone:
Work Number
Home Number
Mother:    
Father:    
Cell Phone:    
Persons to contact in case of emergency:
Phone Number
Address
1.  

 

 
2.  

 

 
Medical Doctor:  

 

 
Dental:  

 

 
  • Permission to administer emergency care to the child if a parent cannot be reached or is delayed
    • Parents Signature:_____________________________________Date:_________________
  • Permission to administer Ipecac Syrup (if needed) to the child as requested by the Poison Control Center
    • Parents Signature:____________________________________Date:__________________
  • Permission to let your child be photographed for public relation purposes while he/she is attending the Learning Funhouse, Inc.
    • Parents Signature:_____________________________________Date:__________________

 

Please list below any special dietary or medical needs of the child: (Doctor's authorization required)

 

 

 

For children ages 6 weeks to 36 months please write a descripton of the child's:

Eating Habits:

 

 

Sleeping Habits:

 

 

Toileting:

 

 

Communication Habits:

 

 

Effective Methods for Comforting:

 

 

Mail or Deliver in Person to:

Learning Funhouse, Inc. -- 199 South Main -- Bird Island, MN, 55310