Scribbles & Giggles Child Care Registration Form

Registration Fee $25.00 (One Time Only & Non-Refundable)

Family Information


Mother/Guardian Information

Father/Guardian Information

Additional Information

My child(ren) will attend the following days. *
Topical Non-Prescription Medication Permission *

Emergency Contacts & Authorized Pick Up List

Important Information

Immunization Record:
Upon enrollment, 1 of the following must be received:
(1) A certificate of immunization showing a minimum of 1 dose of each immunizing agent specified by the department of community health.
(2) A copy of a waiver addressed to the department of community health and signed by the parent stating immunizations are not being administered due to religious, medical, or other reasons.
If we do not receive the correct paper work, your child/children will not be able to attend until it is received in the office.


I agree that I have read and received the Parent Handbook and information packet containing additional policies and procedures. This institution is an equal opportunity provider.
Signature: *
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