* Required Information
WALDORF, MD
2090 Crain Hwy, Waldorf, MD 20601
301-632-3074, FAX 301-632-3075
CALIFORNIA, MD
22789 Three Notch Road,
California, MD 20619
301-866-1830 FAX 301-866-1831
HUGHESVILLE, MD
15260 Prince Frederick Road,
Hughesville, MD 20637
301-632-3074 FAX 301-632-3075
Location
Mother Name/Legal Guardian: *
Home Phone: *
Work Phone: *
Home Address: *
Parent's Birthday:
Cell Phone Carrier:
Father Name/Legal Guardian: *
Home Phone: *
Work Phone: *
Home Address if different from above:
Parent's Birthday:
Cell Phone Carrier:
Date of Birth:
Is this your child's first child care experience?
Yes No
Age:
Child s Name: *
Approximate Arrival and Departure Time:
How did you hear about us?
Email Address: *
Does your child have any allergies or special needs?:
Yes No
If yes, Explain
Two People to Contact if Parent(s) Cannot Be Reached. Please do not provide numbers for people without transportation. Names and Numbers should be updated when necessary.
Name:
Relationship to child
Phone/home/cell:
Name:
Relationship to child
Phone/home/cell:
I do I do not give permission to have my child appear in any media coverage approved by Hughesville CDC. Media coverage includes future usage of photos for advertisement purposes only.
Person(s) NOT Authorized To Pick Up Child. *Appropriate paperwork, such as custody papers shall be attached if parent is not allowed to up the child.
Name(s):
Relationship to child:
By signing this, you agree to the terms listed above.
Signature:
Date

* Security Code