Family Registration

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512-251-7999
tamika@lalc-texas.com
Pflugerville, TX

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Programs
- Infant
- Toddler
- Preschool
- Pre-K
- After School
About
Careers
Parent Forms
Location
Contact Us

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Programs
- Infant
- Toddler
- Preschool
- Pre-K
- After School
About
Careers
Parent Forms
Location
Contact Us

Registration Date

Month

Day

Year

Child Information

1st Child(Required)

First Name M.I. Last Name Nickname

Entering grade(Required)

Gender(Required)

Female

Male

Prefer not to specify

Birth Date(Required)

Month

Day

Year

Birth City/State(Required)

City

State

Existing medical conditions, medications and/or special attention your child may require(Required)

Allergies(Required)

Pediatrician’s Name(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Photos: May we take and maintain a photo of your child for security purposes?(Required)

Yes

No

2nd Child

First Name M.I. Last Name Nickname

Entering grade

Gender

Female

Male

Prefer not to specify

Birth Date

Month

Day

Year

Birth City/State

City

State

Existing medical conditions, medications and/or special attention your child may require

Allergies

Pediatrician’s Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Photos: May we take and maintain a photo of your child for security purposes?

Yes

No

3rd Child

First Name M.I. Last Name Nickname

Entering grade

Gender

Female

Male

Prefer not to specify

Birth Date

Month

Day

Year

Birth City/State

City

State

Existing medical conditions, medications and/or special attention your child may require

Allergies

Pediatrician’s Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Photos: May we take and maintain a photo of your child for security purposes?

Yes

No

Additional Comments & Information:

Primary Guardian Information

Name(s) of person(s) with whom child is living

1st Primary Guardian

First Name M.I. Last Name Relationship To Child

Email Address

Work Phone

Cell Phone

Occupation

Employer

Work Hours

Work Address

Street Address Address Line 2 City State ZIP Code

2nd Primary Guardian

First Name M.I. Last Name Relationship To Child

Email Address

Work Phone

Cell Phone

Occupation

Employer

Work Hours

Work Address

Street Address Address Line 2 City State ZIP Code

Which Guardian Should be Called First?

Home Phone

Preferred language for written communication:

Home Resident Street Address

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different than above)

Street Address Address Line 2 City State ZIP Code

Second Guardian Information

Non-primary custodial parent

1st Non-primary Guardian

First M.I. Last Relationship to Child

Email Address

Work Phone

Cell Phone

2nd Non-primary Guardian

First M.I. Last Relationship to Child

Email Address

Work Phone

Cell Phone

Which Guardian Should be Called First?

Home Phone

Should mailings be sent to this household also?

Yes

No

Second Household Mailing Address

Street Address Address Line 2 City State ZIP Code

Additional Comments & Information:

Emergency Contacts and Authorized Pickups

1st Contact/Pickup

First Last Relationship to Child

Home Phone

Cell Phone

Permission

Able to pick up all children in the family

Not able to pick up the following children

2nd Contact/Pickup

First Last Relationship to Child

Home Phone

Cell Phone

Permission

Able to pick up all children in the family

Not able to pick up the following children

3rd Contact/Pickup

First Last Relationship to Child

Home Phone

Cell Phone

Permission

Able to pick up all children in the family

Not able to pick up the following children

Additional Comments and Information

Is there is any other information that that would be helpful to our management and teaching staff?

Signature

Parent / Guardian Signature(Required)

Date(Required)

Month

Day

Year

15635 Vision Dr # 108, Pflugerville, TX 78660, United States
512-251-7999
tamika@lalc-texas.com

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