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Rainbow Rascals Registration Form

Child Information

Full Name

Date of Birth

Gender

Gender

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)
Program Selection

Additional Services

(Select all that applies)
Additional Services
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.

I, the undersigned parent/guardian, authorize Rainbow Rascals Daycare to seek emergency medical care for my child if necessary.

I, the undersigned parent/guardian, authorize Rainbow Rascals Daycare to capture and post photos of my child for advertising purposes.

I, the undersigned parent/guardian, authorize Rainbow Rascals Daycare to capture and post photos of my child for advertising purposes.

Date