Child's Name (First Middle, Last): *

Child's Name (First, Middle, Last):

First Name

Last Name

Birthdate (MM/DD/YYYY):

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardians' Name: *

First Name

Last Name

Date (MM/DD/YYYY)

MM

DD

YYYY

Home Phone # *

(###)

###

####

Cell Phone#

(###)

###

####

Work Phone #

(###)

###

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Parent/Guardian's Name:

First Name

Last Name

Date (MM/DD/YYYY)

MM

DD

YYYY

Home Phone #

(###)

###

####

Cell Phone#

(###)

###

####

Work Phone #

(###)

###

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Consent *

I hereby consent to the use of photographs (with no names) of my child in promotional materials for CCS

Please provide the name(s) and attach photo ID for any caregiver who may be picking up your child from school.