Registration Form
Please check which day you prefer.
| ___ Tuesday | ___ Wednesday |
Turn form in with $50 registration fee.
According to NC child welfare rules I’m required to make you aware that Toddler Time on Main is not a certified program. We are considered a “short term care” that the State does not require be licensed.
Please sign that you understand & have been made aware.
_________________________________ date _________
Please fill out the below information and turn in with your registration fee.
Childs name __________________________________________________
Childs birth date_______________________ Age _____ Potty trained _______
Parent/guardian names _____________________________________________________
Address_________________________________________________________
(city)________________________ (zip) _____________
Email ___________________________________________
Phone numbers _________________ home ____________________ work __________________ cell
Please list all of your child’s allergies. _____________________________________
_________________________________________________ (____)
Please list any medical conditions I should be made aware _____________________
______________________________________________________________ (____)
Please list any of your child’s favorites (ie. books, songs and/or toys) _________________
_________________________________________________________________________
________________________________________________________________________
| Emergency contact _____________________________________ ___________________ | |
| (name and relation) | (phone) |
| List below others that have permission to pick up your child. | |
| (name and relation) | (phone) |