2024Registration | victorianatureschool

Name of Child

Date of Birth

Identifies as (girl, boy, other)

First Day of Attendance

Parent/Guardian 1 Name & Pronouns

Parent / Guardian 1 Cell Phone

Parent / Guardian 1 Home Phone

Parent/Guardian 1 Email Address

Parent / Guardian 1 Home Address

Parent/Guardian 2 Name & Pronouns

Parent / Guardian 2 Cell Phone

Parent / Guardian 2 Home Phone

Parent/Guardian 2 Email Address

Parent / Guardian 2 Home Address

Child's Care Card Number

Care Card Effective Date

Primary Physician's Name (or clininc name)

Physican or Clinic's Phone Number

Name and Phone Number of Emergency Contacts

Name and Phone Number of Others Authorized to Pick Up the Child

People Not Permitted Access to Child

Please provide documentation of custody orders to Program Coordinator

Names and Ages of Other Children at Home

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