The Children's Learning Palace 24 Hour Daycare Center
1304 Beech Street
Alexandria, LA 71301
(318)449-3939 fax(318)443-3111
info@24hrdaycare.com
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Requested days of attendance : M T W TH F Sat Sun
Indicate full or part time care.
Transportation services needed
If yes, which school does your child attend?
Mother's Information
Father's Information
Please indicate if your child lives with mother,father,or both
Please list address and phone numbers for responsible persons who can pick up your child in case parents cannot be located promptly.
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Medical Information
Past Illnesses:
Allergies/dietary needs or restrictions:
We change diapers every two hours. Please bring 6 diapers/pull-ups, wipes & change of clothes daily.
Please indicate your child's potty training needs: Diapers Pull-ups Completed:
I AUTHORIZE THE FACILITY TO SECURE EMERGENCY MEDICAL TREATMENT FOR MY CHILD.
Parent's signature:
Date: