Preschool Registration

E-mail address

Child's Name

Name Child Wishes to be Called

Home Address

Date of Birth (mm/dd//yyyy)

Home Phone #

Gender

Male

Female

Please List any Allergies or Medical Conditions

Enrolling for Full Day - 5 Days (Monday through Friday)

Enrolling for Full Day (4 days or less - type the days you wish to enroll)

Expected Drop Off time

Expected Pick Up Time

Known Absences (I know my child will not be attending on the following dates)

Parent Information: Child Lives With:

Father's Name

Father Employed By

Father's Address if Different

Father's Cell #

Father's Work #

Mother's Name

Mother Employed By:

Mother's Address if Different

Mother's Cell #

Mother's Work #

Other Emergency Contacts (Name and Phone)

By Checking this Box, I give my permission for my child, named above, to be transported by a Preschool staff member or parent chaperone to and from any activities taking place off campus.