Pre-School Registration Form 2021-22


COMMUNITY PRESBYTERIAN PRESCHOOL REGISTRATION 2021-2022

Date _______________
Gender______

CHILD’S NAME ______________________________________________
first middle last
Nickname if applicable________________________

STREET ADDRESS _________________________________
____________________________________
City, State Zip Code

HOME PHONE__________________
CELL PHONE__________________

CHILD’S BIRTH DATE__________________________
MONTH/DAY/YEAR

ENROLLING IN: (please check the class that applies)
[ ] Preschool (3 year old X 2 days/week) [ ] Pre-Kindergarten (4 year old X 2 days/week)
[ ] Preschool (3 year old X 3 days/week) [ ] Pre-Kindergarten (4 year old X 3 days/week)
[ ] *Preschool (3 year old X 5 days/week) [ ] Pre-Kindergarten (4 year old X 5 days/week)
* Contact the Director for additional information regarding our 3 year old 5 day per week programs.

PARENTS MARITAL STATUS: ____________________
MOTHER’S NAME _________________________ OCCUPATION ____________________
MOTHER’S WORK or Cell Phone # _________________
MOTHER’S ADDRESS (if different) _____________________________________________

FATHER’S NAME _________________________ OCCUPATION ____________________
FATHER’S WORK or Cell Phone # _________________
FATHER’S ADDRESS (if different) ______________________________________________

PARENTS’ HOME CHURCH/DENOMINATION ____________________________________

SIBLINGS (name and age) _____________________________________________________

PREVIOUS SCHOOL OR PROGRAM ATTENDED
__________________________________________________________________________

PEDIATRICIAN OR FAMILY DOCTOR (name & phone) _____________________________
IS CHILD ON ANY MEDICATION? _____ IF YES, DESCRIBE ____________________
DOES CHILD HAVE ALLERGIES? _____ IF YES, DESCRIBE ____________________
PHYSICAL LIMITATIONS? _____ IF YES, DESCRIBE ____________________

SPECIAL NEEDS, HABITS, FEARS, ATTACHMENTS? ______________________________

————————-Emergency Contact Information on the back of this form———————-

PERSONS TO CONTACT IN CASE OF ILLNESS OR EMERGENCY OTHER THAN PARENT (These persons are also authorized to pick up my child)

1. Name ________________________________ Relationship _____________________ Phone ________________ Address ________________________________________

2. Name ________________________________ Relationship _____________________ Phone ________________ Address ________________________________________

Any information you feel necessary to disclose, please list below.