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Child’s Full Name: ____________________________________________
Name used: _________________________________________________
Male ___or Female ____Age____ Birth date: _______________________
month day year
Father’s Name: _______________________________________________
Father’s Occupation: __________________Office Phone: ______________
Mother’s Name: ______________________________________________
Mother’s Occupaiton: _________________Office Phone: ______________
Marital status: Married _____ Divorced_____ Separated_____
Home Address: __________________________________Zip: _________
Home Phone: ______________________Cell Phone: _________________
Church Membership: __________________________________________
Name of child’s physician: ___________________Phone: ______________
In case of emergency, may we call on the nearest doctor? _______________
In case of emergency, please list a neighbor or relative you wish for us to call:
1. ____________________________Phone: _______________________
2. ____________________________Phone: _______________________
Does your child need special care or attention for physical or psychological reason?____________
Please explain: _______________________________________________
Any allergies? _________ If so, what? _____________________________
Please list the name and ages of other children in the family:
_____________________________________________________
_____________________________________________________
To my knowledge, my child is free of any communicable diseases.
Signed: _____________________________________________________
Please select the schedule you desire.
4 year-old 5 Days a Week _______
3 year-old 5 Days a Week _______
3 year-old 3 Days a Week _______
(M/W/F)
Please enclose your $75 registration fee with this form.
Application may be mailed or hand delivered.
See Payment Schedule
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