Stone Church Child Care Center

Registration Form

A completed registration form and $50.00 registration fee holds a spot for your child.  All other paperwork and medical information must be on file a minimum of 24 hours before your child can attend.  You can print this form and drop it off or mail with your check to:  Stone Church Child Care 6330 West 127th St. Palos Heights, IL 60463. You will be contacted if there are no openings available.

Child and Family Information

Child's name: ________________________________  Birthday: ___________________

Nickname: __________________________________  Male/Female: ________________

Age at start date: ________________________ Grade at start date:_________________

Parent's Names: ___________________________________________________________

Daytime phone: _________________________  Evening Phone: ___________________

Usual pick-up person: ________________________________________________________

Scheduled arrival time: __________________  Scheduled departure time: ______________

Name of other persons paying for child care: ______________________________________

Special instructions (Allergies): _________________________________________________

Enrollment Information - please circle all that apply

Fall session and/or Summer session

Child Care:  M  TU  W  TH  F                        Kindergarten Before/After care:  M  TU  W  TH  F

Preschool:  M  TU  W  TH  F                        1st - 6th Grade Before/After care:  M  TU  W  TH  F

How did you hear about the center? _______________________________________________

-----------------------------For office use only - Do not write below this line -------------------------------

Payment Received: $50.00 Cash/Check#_______________ Receipt# ____________________

Authorized by: ______________________  Date application taken:  _____________________

Class assigned: ______________________  Starting Date: _____________________________