South Mebane/Alamance-Burlington Daycare Student Registration 2019-2020
Your child must be a returning daycare student in good standing or a new student to South Mebane.
Email address *
Student ID Number (not applicable to kindergarten or newly enrolled student)
Your answer
Grade Level For 2019-20 School Year *
Type of Care Needed *
Students Name: Last Name, First Name *
Your answer
Child's Date of Birth *
mm/dd/yyyy
Your answer
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 *
Your answer
Work/Phone extension *
Your answer
Cell # *
Your answer
Address *
Your answer
Email *
Your answer
Mother/Guardian *
Your answer
Work/Phone extension *
Your answer
Cell # *
Your answer
Address *
Your answer
Email *
Your answer
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
Your answer
Work/Phone Extension
Your answer
Cell#
Your answer
Address
Your answer
Email
Your answer
Mother/Guardian
Your answer
Work/Phone Extension
Your answer
Cell#
Your answer
Address
Your answer
Email
Your answer
Is there a separation, divorce or custody concern of which our staff needs to be aware? *
Yes, please explain
Your answer
Are you employed by Alamance_Burlington School System? *
If you are an ABSS employee,at what location?
Your answer
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 *
Your answer
Relationship *
Your answer
Phone# *
Your answer
2nd Pick Up Name *
Your answer
Relationship *
Your answer
Phone # *
Your answer
3rd Pick Up Name *
Your answer
Relationship *
Your answer
Phone# *
Your answer
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
Your answer
Prohibited Persons Name
Your answer
Relationship to Child
Your answer
Important Student Information
Please list allergies and needed medications
Please list any allergies *
Your answer
Please list any required medications *
Your answer
Emergency Permission *
Field Trip (If Applicable)
Movie Permission (If Applicable) *
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
Your answer
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