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Date:__________________

I would like my child to be enrolled: MWF_______ TTH______ 5 days_________

Child: ________________________________ Birthdate:____________________

First name child will be called, learn to write and recognize__________________

Home Address______________________________ Phone #:________________

Email :_____________________________________________________________

Mother’s Name: __________________ Father’s Name_______________________

Employed By:____________________ Employed By:_______________________

Cell Phone:______________________ Cell Phone:_________________________

Business Phone:__________________ Business Phone:____________________

Does Child live with both parents?______One Parent:____Other_______________

Any brothers?_______Ages________ Sisters?__________ Ages________

If Parent or guardian cannot be reached in an emergency contact:

Name:_______________________Relationship:____________ Phone#__________

Name:_______________________Relationship:____________ Phone#__________

Who do you authorize to pick up your child other than those listed above?

Names______________________________________________________________

Allergies or other serious problems:_______________________________________

Are there problems that would restrict your child’s activities___________________

____________________________________________________________________

Has your child had all required immunizations?__________

Child’s Dr:____________________________ Phone #________________

Child’s Dentist:_________________________ Phone #_______________

TRAVEL PERMISSION : I give my permission for my child___________________to travel on all field trips with the class.

MEDICAL RELEASE : I, the parent/guardian, ____________________________give permission for emergency aid or treatment, 

as necessary, to render to_______________________by any licensed physician or hospital emergency first aid treatment room 

in the event we can not be reached for consultation.

Signed________________________________________

Additional Information:

Has your child had previous preschool experience?

Please give any information concerning your child which will be helpful in their experiences in preschool. (Fears, play, eating, likes and dislikes)

What goals do you have for your child that you feel the Preschool can enrich?    (Use back of the form if necessary)

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