littleowlsdaycarepreschool@gmail.com
605-718-0132

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Child Registration

So that we can register your child in a timely manner, please complete the form below as completely as you can. All of your information is transmitted to our servers in encrypted form using 256-bit SSL technology.

1Parents/Guardians

2Mother/Guardian

3Father/Guardian

4Child Information

5Contact/Pick Up

6Tuition

7Other Information

Check all that apply*
Check the boxes for the parents/guardians that you will be completing on this form.
- Mother/Guardian
- Father/Guardian

Mother/Guardian
Mother/Guardian Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Occupation
Employed By
Office Phone
Work Hours
Work Address
Street Address Address Line 2 City State ZIP Code
Email
PIN Number for checking in/out*
(4 digits, numbers only)
Marital Status
- Married
- Single
- Divorced
- Separated
- Widowed

Father/Guardian
Father/Guardian*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Occupation
Employed By
Office Phone
Work Hours
Work Address
Street Address Address Line 2 City State ZIP Code
Email
PIN Number for checking in/out*
(4 digits, numbers only)
Marital Status
- Married
- Single
- Divorced
- Separated
- Widowed

Child Information
Child's name*
First Middle Last
Name child prefers to be called
Grade/Class
Address*
Street Address Address Line 2 City State ZIP Code
Gender
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
List any existing medical conditions, medication and/or special your child may require.
Allergies
Pediatrician's Name
Pediatrician's Phone
Pediatrician's Address
Street Address Address Line 2 City State ZIP Code

Emergency Contacts & Authorized Pickup Persons
1st Contact/Pickup
Name
First Last
Phone
Able to pick up all the children in the family
- Yes
PIN Number for checking in/out
(4 digits, numbers only)
Is there a 2nd Pickup?
- Check to add another
2nd Contact/Pickup
Name
First Last
Phone
PIN Number for checking in/out
(4 digits, numbers only)
Able to pick up all the children in the family
- Yes
Is there a 3rd Pickup?
- Check to add another
3rd Contact/Pickup
Name
First Last
Phone
PIN Number for checking in/out
(4 digits, numbers only)
Able to pick up all the children in the family
- Yes
Is there a 4th Pickup?
- Check to add another
4th Contact/Pickup
Name
First Last
Phone
PIN Number for checking in/out
(4 digits, numbers only)
Able to pick up all the children in the family
- Yes

Tuition
Current Tuition Amount
- Weekly
- Bi-Weekly
- Monthly
Please outline below whom is responsible for payment of tuition and fees. Please fill out if parents are divorced and split tuition payment or if tuition payment is the responsibility of an adult other than the parents listed above.

Other Information
Is there any other information that would be helpful to our management and teaching staff?
Signature*

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