Republic of the Philippines

MUNICIPAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Municipality of San Vicente

Barangay San Jose

REGISTRATION FORM

Name of the Child:

Last Name First Name Middle Name

Date of Birth :

Address :

Mother’s Name :
Last Name First Name Middle Name
Father’s Name :

Last Name First Name Middle Name

Facebook Account:

Contact Number :

PLEDGE OF COMMITMENT
We, pledge to enroll my child
(Name of the Parents/ Guardian)

in SAINT JOSEPH CHILD DEV’T CENTER ,

( Name of the Child ) ( Name of the Day Care Center )

for the school year -- and to promise to actively participate/contribute

in whatever activities in the center.

Parent/Guardian
Signature over printed name
Approved by: EMMA D. DIONEDA
Child Development Worker