CHILD'S NAME: ____________________________________________________________________
AGE: ________________________________ BIRTHDATE: __________________________________
HEIGHT: _____________________________ WEIGHT: _____________________________________
MOTHER'S NAME: _______________________ FATHER'S NAME: ___________________________
PHONE NUMBER: ___________________________________________________________________
ADDRESS: _________________________________________________________________________
EMERGENCY PHONE NUMBER: ______________________________________________________
DOCTOR'S NAME: __________________________________________________________________
PREFERRED HOSIPTAL: ______________________________________________________________
WHO WILL BRING AND PICK UP THE CHILD? __________________________________________
NAME AND AGE OF SIBLINGS: _______________________________________________________
FOOD PREFERENCES OR DISLIKES: ___________________________________________________
FOOD ALLERGIES: __________________________________________________________________
WOULD YOU CONSENT TO THE USE OF YOUR CHILD'S PICTURE FOR PUBLICITY REASONS AT WEST LEYDEN? __________________________________________________________________________________