Record Update Form – The Preferred Choice

Child’s Full Name

Sex

Age

Date of Birth

Child’s Home Telephone

Child’s Home Address

Child's Home Address

City

State/Province

Zip/Postal

Mother’s Contact Details

Mother’s Name

Telephone Number

Mother’s Home Address

Same As Child’s Home Address

Different Address

Mother’s Home Address

Mother's Home Address

City

State/Province

Zip/Postal

Place of Employment

Business Number

Address of Employment

City

State/Province

Zip/Postal

Father’s Contact Details

Father’s Name

Telephone Number

Father’s Home Address

Same As Child’s Home Address

Different Address

Father’s Home Address

Father's Home Address

City

State/Province

Zip/Postal

Place of Employment

Business Number

Address of Employment

City

State/Province

Zip/Postal

Child’s Living Arrangements

Both Parents

Mother

Father

OtherOther

Child’s Legal Guardian

Both Parents

Mother

Father

OtherOther

This child may be released to the person(s) signing this agreement or the following.

Name

Address

Add Person Remove Person

Person to contact in case of an emergency when parents cannot be reached

Name

Phone

Add Contact Remove Contact

Your Full Name

Your relationship to the child

Your Email Address

Your Contact Number

Declaration

I hereby confirm that I have read and understood the Terms and Conditions of The Preferred Choice and by submitting this form I agree to abide by all those terms and conditions, throughout my child’s enrollment period at The Preferred Choice.

Signature

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