License Number: C12MA0273
Please call for part-time prices
Name(Mother or Guardian #1):
Mother's Cell Phone:
Mother's Place of Employment:
Mother's Work Phone:
Name(Father or Guardian #2):
Father's Cell Phone:
Father's Place of Employment:
Father's Work Phone:
(Please register each child separately)
Child's First Name*:
Child's Last Name*:
City*: State*: FloridaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Child Resides With:
Mother Father Both Neither
Custody or Visitation Guidelines:
Emergency Contact #1::
Relationship to Child:
Emergency Contact #2::
If I am unable to pick up my own child, I give permission for my child to be released to the following individuals:
My Child MAY be released to Contact #1
Relation to Child:
My Child MAY be released to Contact #2
My Child MAY be released to Contact #3
My Child MAY be released to Contact #4
My child may NOT be released to the following individuals listed below.
My Child may NOT be released to the following individual
Other important information:
I understand that all persons picking up my child from school MUST show proof of their identity with a valid Driver’s License. If they are unable to produce valid identification, the Lily School staff will NOT release my child into that individual’s custody.
Upon final registation with the Lily School staff you will sign acknowledging you understand the above statement.
350 Braden Ave.
Sarasota, FL 34243
7:30 a.m. - 5:30 p.m.
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