Old Bridge Township Before & After School Day Care Program REGISTRATION FORM
Enrollment Date, Starting: Termination Date, As of:
Child's Name Date of Birth
Child's School Grade
Program Choice - Please select one A B C D Number of Days: M T W TH F
Mother's Name Father's Name
Home Address:
Mother's Employer: Father's Employer
Mother's Home Phone No: Father's Home Phone No:
Mother's Business Phone: Father's Business Phone:
Mother's Cell Phone: Father's Cell Phone:
Below is a list of individuals, other than myself, who are authorized to pick up my child(ren) from the Before & After School Day Care Program in case of an emergency or illness when a parent or guardian is not available. Minimum of 2 LOCAL emergency contacts.
Name: Home Phone: Cell Phone:
Child's Physician: Physician's Phone:
By my signature, I attest to the following:
That the above information is correct; That in the event of a medical emergency, I authorize the Township of Old Bridge Before & After School program to seek medical care deemed necessary; That I have received information to Parent's Document. (Please return appropriate sign off sheet to your child's center). Parent's Signature Custodial Information: If non-custodial parent is not included among those persons authorized by the custodial parent to pick up the child, please explain below and attach a copy of the court order.
Parent's Signature
Custodial Information: If non-custodial parent is not included among those persons authorized by the custodial parent to pick up the child, please explain below and attach a copy of the court order.