Child Care Registration Form
Phone: 262-782-3040; Email: SchoolOffice@ChristTheLordBrookfield.org
Hours: 11:30 a.m. - 5:30 p.m.; Rate Per Hour: $5.00; Additional Sibling: $2.50.
Billing: Invoices are emailed on a monthly basis.
STUDENT INFORMATION
First & Last Name *
Your answer
Grade *
HEALTH CONCERNS
Ex: Regular medications, special health problems, allergies, including drug reactions, other important information.
Health Concerns - Yes or no? If yes, specify
Your answer
CHILD CARE REQUEST
Start Date *
MM
/
DD
/
YYYY
Pick Up When *
Time
:
REOCCURING *
Specify all that apply *
Required
PARENT INFORMATION
Parent First & Last Name *
Your answer
Parent Primary Phone (include area code) *
Your answer
OTHER CONTACT PICKING UP
Other Contact First & Last Name
Your answer
Other Contact Primary Phone (include area code)
Your answer
Submit
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