Child Registration Form - Virginia

DIVISION OF LICENSING PROGRAMS
DEPARTMENT OF SOCIAL SERVICES
CHILD REGISTRATION FORM
Name Nickname Date of Birth Sex
Address Home Phone
Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed
Previous Child Day Care Programs and Schools Attended
If Child Attends this Center and Another School/Program, Give Name of School/Program Grade
PARENT(S)/GUARDIAN(S)
Father Place Employed Business Phone
Home Address Home Phone
Mother Place Employed Business Phone
Home Address Home Phone
Person(s) or Agency Having Legal Custody of Child
Home Address Home Phone
Business Address Business Phone
EMERGENCY INFORMATION
Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency
Child’s Physician Phone
Two People to Contact if Parent(s) Cannot
Be Reached
1.
Address
1.
Phone
1.
2.
2.
2.
Person(s) Authorized to Pick Up Child
Person(s) NOT Authorized to Pick Up Child *
* Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.
* NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the
noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of
such noncustodial parent, as an emergency contact for events occurring during school or day care activities.
032-05-252/11 (06/05) (over)
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