HOLY SPIRIT SCHOOL

 AFTER/BEFORE-CARE PROGRAM

970 SUBURBAN ROAD

UNION, NEW JERSEY 07083

CHILD CARE REGISTRATION FORM

Child's Name __________________________________________________________

                                    Last                                    First

Before Care ___    After Care ___       Grade _______________                        Age ___________

Home Address ______________________________                        Phone # _________________

Mother's Name _____________________________

Business Name _____________________________ Phone # _________________

Business Hours _____________________________

Father's Name _______________________________

Business Name ______________________________ Phone # _________________

Business Hours ______________________________

Local Person to be contacted in an emergency, if parents cannot be located:

Name _______________________________________     Relationship _______________________

Address ______________________________________       Phone # __________________________

Name _______________________________________     Relationship _______________________

Address ______________________________________       Phone # __________________________

Child's Doctor ________________________________

Address _______________________________________     Phone # _________

List all persons approved to pick up child (CHILD WILL NOT BE RELEASED TO ANYONE ELSE WITHOUT SPECIFIC PERMISSION)

Name _______________________________________     Phone # __________________________

Name _______________________________________     Phone # __________________________

Name _______________________________________     Phone # __________________________