Please fill out this Registration application, you'll be contacted with an appointment when application received.

Location you 're interested in: 397 Grand St.       238 Straight St. 

Child's Information

Child's Name    Start Date 

 Address                

  Telephone #     

 S.S. #            Birth Date  

Father's Name    Address       

  Telephone #         S.S. #

Mother's Name    Address  

 Telephone #           S.S. #   

Parents' are: Single Married Separated Divorced

How many other children living with parents:   

Name(s) Age(s)

Father's Information

Work/ School: Address

Telephone #    Ext:   Supervisor  

 Hours/Shift    

Gross Pay     

Mother's Information

Work/ School: Address

Telephone #    Ext: Supervisor  

Hours/Shift    

Gross Pay     

Emergency Contacts

 (1) Name           Address

 Phone  (Home)                (Work) 

 (2) Name          Address

  Phone  (Home)               (Work)

 (3) Name          Address

  Phone  (Home)     (Work)

 (4) Name          Address

 Phone  (Home)      (Work)

Other Information

Child's Doctor Telephone #

Does your child have any allergies?

To food?            Yes         No             If yes, specify

To medicine?     Yes         No             If yes, specify

Is there any food your child can not eat because of religious reasons?

Yes         No             If yes, specify

Is your child currently on any medication?

Yes         No             If yes, specify

Permission

 I give permission for my child to participate in the Memorial Day Nursery Program. In Case of accident or injury, I give permission for my child to receive medical treatment from any doctor or hospital judged necessary by the management of the Memorial Day Nursery of Paterson.

Parent or Guardian Name              Parent or Guardian initial here