Red Robin's Academy
Child Care Application
Child's Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Male or female?
Female
Male
Parent's Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email address
example@example.com
Estimated Yearly Income:
Emergency Contacts:
Name
First Name
Last Name
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Other people authorized to pick up your child from school
Name
First Name
Last Name
Name
First Name
Last Name
Medical information
Doctor's Name
First Name
Last Name
Doctor's Phone Number
Please enter a valid phone number.
Preferred hospital
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Submit
Should be Empty: