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CCF ENROLLMENT FORM
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* Indicates required question
CHILD'S NAME
*
Your answer
PARENT OR GUARDIAN
*
Your answer
BIRTHDAY
*
MM
/
DD
/
YYYY
AGE
*
Your answer
TELL US ABOUT YOUR CHILD.
Your answer
ADDRESS
*
Your answer
PHONE NUMBER (main point of contact)
*
Your answer
EMAIL
*
Your answer
EMERGENCY CONTACTS (Name/#) if you can't be reached
*
Your answer
FOOD ALLERGIES?
*
YES
No
Required
FOOD ALLERGIES-->
*Please indicate if it's for allergic reaction or diet
Your answer
NAMES AND NUMBERS OF PEOPLE WHO CAN PICK UP YOUR CHILD.
*
Your answer
NAME AND NUMBER OF PHYSICIAN
*
Your answer
May we publish your child’s picture in (newspaper, newsletter, internet, etc…) without child’s name?
*
YES
No
Required
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