Registration Form Please enable JavaScript in your browser to complete this form.Name *FirstLastAre you an employee of the Lifespan network? *YesNoDaytime Phone *Email *What is the best time to reach you? *Child's InformationFull Name of Child *FirstLastChild's Date of Birth *Gender *FemaleMaleChild's Home Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Emergency Contact *FirstLastEmergency Contact Phone *Authorized to Pick Up Your ChildPlease list up to three additional people who have your permission to pick up your child.Name 1 *FirstLastPhoneName 2FirstLastPhoneName 3FirstLastPhoneDetails About Your ChildIs your child potty trained? *YesNoPlease bring an adequate daily supply of pull ups when you drop your child poff each day.I agree to bring pull ups.Does your child have any medical conditions? *YesNoPlease give details about your child's medical condition(s).Does your child have any special dietary requirements? *YesNoPlease give details about your child's dietary requirements.Does your child have any allergies? *YesNoPlease give details about your child's allergies.Does your child have any behavioral issues that require a special plan? *YesNoPlease give details about your child's behavioral issues and plan.If you have active restraining order on behalf of your child or a custody agreement, please enter that information below. Desired Weekly ScheduleMonday HoursTuesday HoursWednesday HoursThursday HoursFriday HoursUpload DocumentsUpload an image of your driver's licence. Upload an image of your child's insurance card. Upload an image of your child's immunization record. Basic Guidelines You Must Agree ToAt this time, all children must bring their own lunch. *I understand and I agree350 Point Street is a nut free building. Please do not bring in or allow your child to bring in any nut products. This includes peanut butter. *I understand and I agreePlease make sure your child has appropriate clothing for going outside to play on our secure playground. *I understand and I agreeEmailSubmit
