Hawfields Middle School/Alamance-Burlington Daycare Student Registration 2021-2022
Your child must be a returning daycare student in good standing prior to filling out this form. If you have any questions please call the front office (919-563-5303)
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Email *
Pre-Registration Required  with front office?(School Use Only) *
Student ID Number (not applicable to kindergarten) *
Email address *
Grade Level For 2021-22 School Year *
Students Name: Last Name, First Name *
Child's Date of Birth *
mm/dd/yyyy
PRIMARY Parent/Guardian names, phone numbers, address, and e-mails *
Format: First & Last Name, Phone #s (specify cell, day, and home), Address, Email (If ABSS employee, please provide both ABSS email and an email address other than your ABSS address.)
Father/Guardian *
Work/Phone extension *
Cell # *
Address *
Email *
Mother/Guardian *
Work/Phone extension *
Cell # *
Address *
Email *
SECONDARY Parent/Guardian names, phone numbers, address, and e-mails *
Format: First & Last Name, Phone #s (specify cell, day, and home), Address, Email (If ABSS employee, please provide both ABSS email and an email address other than your ABSS address.)
Father/Guardian *
Work/Phone Extension *
Cell#
Address *
Email *
Mother/Guardian *
Work/Phone Extension *
Cell# *
Address *
Email *
Is there a separation, divorce or custody concern of which our staff needs to be aware? *
Yes, please explain *
Are you employed by Alamance_Burlington School System? *
If you are an ABSS employee,at what location? *
Emergency Contact and Pick Up authorization
The following people may pick up the child from the program and/or be reached during an emergency. In the event of inclement weather or an emergency situation. Please make sure you have made arrangements with these individuals to pick up your child/children from the program and they are accepting of this responsibility.**Please note a valid ID will be required to pick up students from daycare.
1st Pickup Name *
Relationship *
 Phone# *
2nd Pick Up Name *
Relationship *
Phone # *
3rd Pick Up Name *
Relationship *
Phone# *
Is there any person prohibited from picking up the child by a court order? *
If yes, attach a copy of the court order and an explanation *
Prohibited Persons Name *
Relationship to Child *
Important Student Information
Please list allergies and needed medications
Please list any allergies *
Please list any required medications *
Emergency Permission *
Field Trip (If Applicable) *
Movie Permission (If Applicable)
Clear selection
Homework Preference (note this option may not be available at you school please check with each individual location) *
Participation and Payment Agreement *
Questions and comments
A copy of your responses will be emailed to the address you provided.
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