Admission Form Providence

ADMISSION INFORMATION

Operation Name

The Kid’s Corral

Director’s Name

Providence Village – Minette McGuire

Child’s Full Name

Child’s Date of Birth

Child’s Home Telephone No.

Child’s Home Address

Date of Admission

Date of Withdrawal

Parent’s or Guardian’s Name

Home Address (if different from child’s address )

Mother’s Place of Employment:

Father’s Place of Employment:

Mother's Drivers License Number

Father's Drivers License Number:

Mother's E-mail Address:

Father's E-mail Address

List telephone numbers below where parents/guardian may be reached while child will be in care:

Mother’s Cell No.

Mother’s Work No.

Father’s Cell No.

Father’s Work No.

Guardian’s Telephone No

Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached:

Relationship

I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name & telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

Parent/Person 1

Parent/Person 2

Parent/Person 3