Registration and info

page 1

Loyola village preschool

and

Kaihani Family child care registration

(Please make sure that space is available then fill up this form)

Name: First

Middle

Last

	YYYY-MM-DD
	Date of birth

Boy Girl

	YYYY-MM-DD
	First day of care

Days and hours of Care needed :

Monday Tuesday Wednesday Thursday Friday

From To

	YYYY-MM-DD
	Last day of care

Home address and phone number

Street

City

State

Zip code

Home phone (xxx) xxx-xxxx

Parents names and contacts:

Mom's name first

Middle

Last (if different)

Mom's cell (xxx) xxx-xxxx

Work phone (xxx) xxx-xxxx

Dad's Name first

Middle

Dad's cell (xxx) xxx-xxxx

Work phone (xxx) xxx-xxxx

Web address(URL):

Mom's

Dad's