LAKESHORE TECHNICAL COLLEGE
CHILD CARE CENTER
REGISTRATION/PERMISSION
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*************************************CHILD INFORMATION***********************************
NAME:________________________________ ADDRESS___________________________
AGE:_________________________________ ____________________________________
DOB:_________________________________ ____________________________________
ETHNICITY DATA : Caucasian - Hispanic or Latino - American Indian -Alaska Indian - Asian - African American
Native Hawaiian or Other Pacific Islander (please circle one)
____________________________________________________________________________________________
***********************************PARENT INFORMATION************************************
PARENT:___________________________ ADDRESS___________________________
PHONE #:___________________________ ____________________________________
PARENT:___________________________ ADDRESS___________________________
PHONE #:___________________________ ____________________________________
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_____STAFF(work division or ext.)____________________ ID#__________________________________
_____STUDENT(program/course)_____________________ ID#__________________________________
_____COMMUNITY(employer)_______________________ SS#__________________________________
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PLEASE INDICATE THE DAYS AND TIMES THAT YOU NEED
MON________