Time to Shine Learning Center Registration Form
Please complete each section of this form.  If you are registering multiple children, a separate form must be completed for each child.
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Child's Last Name *
Child's First Name *
Child's Middle Name (If not applicable, type N/A) *
Child's Preferred Nickname (If not applicable, type N/A) *
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Gender *
Please check service(s) requested: *
Required
If your child is school age, please list the school and address. (Write N/A if not applicable). *
Which days will you need services? *
Required
Preferred hours requested (Please note that a childcare day equals 10 hours. There is an additional $20 fee per day for any child in our care longer than that). *
Name of Parent/Guardian   *
Home Address *
Mobile Phone Number(s) *
Email Address(es) *
Preferred Method of Communication *
Emergency Contact #1 Name and Phone *
Emergency Contact #1 Relationship *
Emergency Contact #2 Name and Phone
Emergency Contact #2 Relationship *
Who is able to pick up your child in the event of an emergency? *
Please list any of the following: current medications, medication allergies, food allergies, or chronic health concerns. *
Doctor's Name/Address/Phone *
Preferred Hospital *
Insurance/Health Coverage *
Is there anything else you would like for us to know? *
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