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Learning Center Registration 2016-17 Program Year @ Union Cong
All participants must register and supply medical info no matter how frequently or infrequently you plan to attend.
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* Indicates required question
Will your child(ren) attend Union Cong Learning Centers or Childcare for 2016-17 year?
*
if you are not sure, check yes
Yes
No
Parent Name(s)
*
Your answer
#1 Child Name
*
LCs are for children 3 years old through 7th grade, childcare under 3 years
Your answer
#1 Child date of birth
*
month, day, year
MM
/
DD
/
YYYY
#1 Child grade in school beginning Fall 2015
use NA if not in school
Your answer
List any medical conditions or medications for child #1
list anything else you think we should know or NA if not applicable
Your answer
#2 Child Name
Your answer
#2 Child date of birth
month, day, year
MM
/
DD
/
YYYY
#2 Child grade in school beginning Fall 2015
use NA if not in school
Your answer
List any medical conditions or medications for child #2
list anything else you think we should know or NA if not applicable
Your answer
#3 Child Name
Your answer
#3 Child date of birth
month, day, year
MM
/
DD
/
YYYY
#3 Child grade in school beginning Fall 2015
use NA if not in school
Your answer
List any medical conditions or medications for child #3
list anything else you think we should know
Your answer
Family Address
# - Street - City - zip
Your answer
Best contact phone #
indicate home or cell
Your answer
Best contact email, may list more than one
occasionally we will send Faith to Home materials
Your answer
Are you available to teach on a substitute basis?
We have paid teachers but in the event of an absence, parents may be asked for help.
yes
no
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