Angel’s Korner Daycare & Learning Center

Angel’s Korner Daycare & Learning Center

517 Braxton Rd

Front Royal, Va 22630

[phone] Main Office

Child’s Name Nickname Date of Birth Sex

Address Home Phone
Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed
Previous Child Day Care Programs and Schools Attended If Child is School Age, Please List School and Grade

Father Place Employed Business Phone

Home Address Home Phone
Cell Phone /Other Numbers Where You May Be Reached E-Mail Address

Mother Place Employed Business Phone

Home Address Home Phone
Cell Phone/Other Numbers Where You May Be Reached E-Mail Address

Person(s) or Agency Having Legal Custody of Child

Home Address Home Phone
Business Address Business Phone

Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency

Child’s Physician Office Phone
Two People to Contact if Parent(s) Cannot Be Reached: They CANNOT have the same address as either parent
1._________________________________________________________________________________________________

Name Address Phone Number(s)

2._________________________________________________________________________________________________

Name Address Phone Number(s)

Person(s) Authorized To Pick Up Child
Person(s) NOT Authorized To Pick Up Child

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  Appropiate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.
  

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  NOTE: Section 22.1 – 4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities.