Registration Application
 
Thank you for your interest in Prairie Child Care.
Please note that this online registration is only the first part of the registration process,
and you must complete additional paperwork before your child is enrolled in a Prairie Child Care program.
 
 If you are unable to add a child at the end of this form, please check over your entries to ensure
that every required space has some text entered. If a field does not apply to you or your family, 
please write NA in order to move forward with the registration. 

If you have any questions about the online registration application, please contact our main office at 708-323-2818. 

Parent/Guardian #1 Information
(This person will receive all mail/billing information and is responsible for tuition payments.)
* First Name 
* Employer 
* Last Name 
* Employer Address 
* Address 
* Employer City 
   * Employer State 
* City 
* Employer Zip 
* State 
* Work Phone 
xxx-xxx-xxxx 
* Zip 
  Extension 
* Email 
* Work Hours 
* Home Phone 
xxx-xxx-xxxx 
* Relationship 
to student 
* Cell Phone 
xxx-xxx-xxxx 
  If "Other," 
please specify 


Parent/Guardian #2 Information
  First Name   Employer 
  Last Name   Employer Address 
  Address   Employer City 
     Employer State 
  City   Employer Zip 
  State   Work Phone 
xxx-xxx-xxxx 
  Zip   Extension 
  Email 
  Work Hours 
  Home Phone 
xxx-xxx-xxxx 
  Relationship 
to student 
  Cell Phone 
xxx-xxx-xxxx 
  If "Other," 
please specify 


Primary Persons Authorized To Pick Up Child Regularly: (other than parents)
     Person 1       Person 2  
* First Name 
* First Name 
* Last Name 
* Last Name 
* Relationship 
to student 
* Relationship 
to student 
  Home Phone 
xxx-xxx-xxxx 
  Home Phone 
xxx-xxx-xxxx 
  Work Phone 
xxx-xxx-xxxx 
  Work Phone 
xxx-xxx-xxxx 
* Cell Phone 
xxx-xxx-xxxx 
* Cell Phone 
xxx-xxx-xxxx 
  Address   Address 
  City   City 
  State   State 
  Zip   Zip 


Contingency List of Persons Authorized to Pick Up Child Occasionally
     Person 1       Person 2  
* First Name 
* First Name 
* Last Name 
* Last Name 
* Relationship to Student 
* Relationship to Student 
  Home Phone 
xxx-xxx-xxxx 
  Home Phone 
xxx-xxx-xxxx 
  Work Phone 
xxx-xxx-xxxx 
  Work Phone 
xxx-xxx-xxxx 
* Cell Phone 
xxx-xxx-xxxx 
* Cell Phone 
xxx-xxx-xxxx 
  Address   Address 
  City   City 
  State   State 
  Zip   Zip 
* Conditions for releasing student(s) to this person (ex: parent phone call, emergency, can pick up anytime): 
* Conditions for releasing student(s) to this person (ex: parent phone call, emergency, can pick up anytime): 


Non-Parent/Guardian Adult Emergency Contacts
(Please list two individuals who may be contacted in an emergency situation. They must be in close proximity to your child's school and at least 18 years of age.)
     First Contact       Second Contact  
* First Name 
* First Name 
* Last Name 
* Last Name 
* Relationship 
to student 
* Relationship 
to student 
  Home Phone 
xxx-xxx-xxxx 
  Home Phone 
xxx-xxx-xxxx 
  Work Phone 
xxx-xxx-xxxx 
  Work Phone 
xxx-xxx-xxxx 
  Extension   Extension 
* Cell Phone 
xxx-xxx-xxxx 
* Cell Phone 
xxx-xxx-xxxx 
* Address 
* Address 
* City 
* City 
* State 
* State 
* Zip 
* Zip 


Payment of Registration Fee
     
If you are registering for the 2017-2018 school year, Prairie requires a $97.00 non-refundable, annual registration fee.This fee can be paid online at the end of this form with a credit card or in our office at the time of registration.

If you are registering for the 2017 summer program, a registration fee of $47.00 per child must be paid in the office at the time of registration.

I intend on paying:  
* Payment Choice: 


Additional Information
* How did you hear about Prairie Child Care? 
  Referred by: 


Registered Students
  
You have not registered a student at this time.
 



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