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Rainbow Rascals Registration Form
Child Information
Full Name
*
Date of Birth
*
Gender
*
Male
Female
Full Home Address
*
Allergies / Medical Conditions
*
Special Needs (if any)
*
Parent / Guardian Information
Full Name
*
Primary Contact
*
Secondary Contact
*
Email Address
*
Emergency Contact
Full Name
*
Contact #
*
Relationship to child
*
Program Selection
*
(Select all that applies)
Additional Services
*
(Select all that applies)
Authorized Pickup Persons
(Other than Parents and Guardians)
Name
*
Contact
*
Relationship to Child
*
Name #2
*
Contact
*
Relationship to Child
*
Medical Authorization
I, the undersigned parent/guardian, authorize Rainbow Rascals Daycare to seek emergency medical care for my child if necessary.
*
Yes
No
I, the undersigned parent/guardian, authorize Rainbow Rascals Daycare to capture and post photos of my child for advertising purposes.
*
Yes
No
Date
*
Submit