Toddler Registration

Complete the form below to register your toddler (18 months–3 years). When you submit, it comes straight to our office.

1477 South Schodack Road, Castleton, NY 12033 · (518) 477-7103

Child information

Child's full name *

Nickname

Telephone

Desired start date *

Date of birth *

My child will attend *

Timing *

Date of last medical exam

Allergies

Enter N/A if none

Pediatrician

Enter N/A if none

Developmental concerns

Enter N/A if none

Home address

Street *

Apt.

City *

State *

Zip *

Parent information

Mother

Cell phone

Father

Cell phone

Emergency information

Mother — daytime location

Mother — daytime phone

Father — daytime location

Father — daytime phone

Emergency contact person *

Relationship to child *

Telephone *

Parent's signature

I certify that the information provided above is accurate to the best of my knowledge.

Sign above with your finger or mouse.