S/D ____________                                                     160 East Main St., Clinton, CT 06413              Registration for:
                                                                                                   Phone: 860-669-4315
    Program ________                                                                                 Fax: 860-669-4964                       Full Year Program ____
                                                                                                                                                                        OR
    Year ___________                                                                                                                        Reduced/Summer Off ___

    Child's Name: _____________________________________    Birth Date: __________________    Age: ____________

    School (if applicable): _________________________________   Grade: _________ Teacher: __________________

    Child's Home Address: ________________________________________________ Phone: _____________________

    Guardian #1's Name: ________________________________________________ Home Phone: ________________

    Guardian #1's Address: __________________________________________________________________________

    Business Phone: ___________________    Cell Phone: _______________    Email Address: ____________________

    Guardian #1's Employer Name and Address: __________________________________________________________

    Guardian #2's Name: ________________________________________________ Home Phone: ________________

    Guardian #2's Address: __________________________________________________________________________

    Business Phone: ___________________    Cell Phone: ________________    Email Address: ___________________

    Guardian #2's Employer Name and Address: _________________________________________________________

    Days and hours of service needed: _________________________________________________________________

    Names and addresses of those authorized as an emergency alternative pick up (We must receive notice the day of when     you send an alternative pick up)

    1) ___________________________________________________________ Phone: _____________________

    2) ___________________________________________________________ Phone: _____________________

    3) ___________________________________________________________ Phone: _____________________

    4) ___________________________________________________________ Phone: _____________________

    Child's Doctor: _________________________________________________ Phone: _____________________

    Child's Dentist: ________________________________________________ Phone: _____________________

    Health Insurance Company / Number: _____________________________ Medicaid Number * _____________
                                                                                                                                                                                         *if applicable 
    I give my consent for my child to:
    a) Receive emergency medical care as deemed necessary by the staff of Clinton Child Care        __ Yes    __ No    
    b) Use parent provided sunscreens while at Clinton Child Care​                                                       __ Yes    __ No 
    c) Use parent provided insect repellent while at Clinton Child Care                                                 __ Yes    __ No
​    d) Participate in any Clinton Child Care adult supervised walking trip                                              __ Yes    __ No 
    e) Use of child's photograph for Facebook, website and advertising use                                         __ Yes    __ No
        
    _____________________________________________________________ / __________________
    Signature of Parent or Guardian / Date
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