Child’s Name_________________________ Birth Date____________ M _____F_____

Father’s Name______________________ Driver’s License No. ___________________

Address _________________________ City, State, Zip Code ____________________

Home Phone _______________________

Father’s Business Place _____________________ Business Phone _______________

Business Address ___________________________________ Work Hours _________

Mother’s Name ______________________Driver’s License No. __________________

Address __________________________City, State, Zip Code ___________________

Home Phone _______________________

Mother’s Business Place _____________________ Business Phone ______________

Business Address ___________________________________ Work Hours _________

Person or persons authorized to pick up child:

Name _____________________ Telephone and address _______________________

Name _____________________ Telephone and address _______________________

Time: From _______ To _______ Days: M T W TH F Beginning Date ___________

Person responsible for tuition: ________________________________

• A child who appears ill upon arrival shall not be admitted to the DWU Daycare.

• When a child becomes ill at Daycare, the parents shall be contacted and arrangements made for the child to be picked up immediately. This determination will be made by the Daycare.

• The Daycare may require a written permission slip before reentry to the Daycare is permissible.

At the time of registration, the parents should authorize the child’s physician to accept all calls from the child care director for emergency medical care.