Abundant Life Child Development Center Registration Form
17 Third Street Keyport, NJ 07735 732-888-7787
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Child's Information
First and Last Name *
Date of Birth *
MM
/
DD
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YYYY
Parent/Guardian Information
Name(s) *
Home Address *
Work Address *
Home Phone Number *
Work Phone Number *
Cell Phone Number *
Person Authorized to Pick up Your Child in Case of Emergency
Contact 1
Full Name *
Address *
Phone Number *
Relationship *
Contact 2
Full Name *
Address *
Phone Number *
Relationship *
Name of Person(s) Prohibited from Picking up your Child
If a non-custodial parent is NOT included among those person(s) authorized by the custodial parent to pick up the child, please explain below and attache a copy of the appropriate court documents.
Please list names below.
Healthcare Information
Child's Doctor - Name, Telephone Number and Address *
Type of Program Requested
Requested Start Date *
MM
/
DD
/
YYYY
Hours of care *
Days *
I give permission for my child to participate in walking trips within the center's neighborhood. *
I would like to register my child with Abundant Life Child Development Center for the program indicated above. Prior to start date, I will review the enrollment package and complete and return the necessary documents. On or before my child's start date, I will pay the non-refundable $50 registration fee. By clicking the box below, I understand that is a valid electronic signature. *
Required
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