PurePlay Child Care - Registration Request Form

Hours: 6:30am - 5:30pm

Email: info@pureplaychildcare.com

Pure Play Child Care Play is our Curriculum

Fields marked with are required

Please Note: This form is for an initial registration request only. Once your initial request is recieved, we will follow up with you. A complete registration package must be completed and submitted upon your child's first visit.

Full Name of Child

Gender

Birthdate

Language(s) spoken at home

Registration Date

Parent or Guardian Full Name

Address

Cell / Phone Number

Other Phone Number

2nd Parent or Guardian Full Name

2nd Address

2nd Email

2nd Cell / Phone Number

2nd Phone #

Authorized Pick-up Personnel

Name 1

Relationship to the Child 1

Phone 1

Cell Phone 1

Name 2

Relationship to the Child 2

Phone 2

Cell Phone 2

Name 3

Relationship to the Child 3

Phone 3

Cell Phone 3

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Registration Request Form

Authorized Pick-up Personnel

Full Registration Forms

Address

Address

Address

Address