Central Baptist Church

Program Philosophy

Child Care - Registration

Please complete the application below or print a copy to submit via mail.

Child's Name:
Birthdate:
Gender:		Age:
Home Phone:
Child Care Times:	Monday:
	Tuesday:
	Wednesday:
	Thursday:
	Friday:

Parent 1 (Guardian)
Name:
Marital Status:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Working Days and Times:	Monday:
	Tuesday:
	Wednesday:
	Thursday:
	Friday:
Employer:
Address:
City:
State:
Zip:
Work Phone:
Parent 2 (Guardian)
Name:
Marital Status:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Working Days and Times:	Monday:
	Tuesday:
	Wednesday:
	Thursday:
	Friday:
Employer:
Address:
City:
State:
Zip:
Work Phone:

Child Resides with:
	# of people in family:
Beginning Date Desired:
Notice to Current provider:

420 N. Roy
St. Paul, MN 55104
Office: 651.646.2751
Fax: 651.646.0372