2016-17 HOWELL EARLY LEARNING CENTER REGISTRATION FORM
 

Name of Child (Last, First, Middle Initial)
Address
City
State
Zip Code
Home Phone
Cell Phone
Home Address (if not child's address
Home Phone
Cell Phone
Home Address (if not child's address
Work Phone
Work Phone
Name of Child's Physician or Health Clinic
Physician or Health Clinic Number
Hospital Preferred for Emergency Treatment (optional)
Allergies, Special Needs and Specail Instructions



Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preferencem to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in emergency and to whom the child can be released. The second phone number column can be left blank.



Release of Child Only:List all individual, Other than The parents/guardians, to whom the child may be released.