Check One:    Preschool   Childcare

*Child's Name (required):

Name used at home:

Date of Birth:         Present Age:    

Sex:     Male   Female

Is your child toilet trained?     Yes   No

Address:

City:         Zip Code:    

Home Phone #:         Cell Phone #:    

Father's Name:

Place of Employment:

Occupation:

Work Phone #:    

Mother's Name:

Place of Employment:

Occupation:

Work Phone #:    

Name of church you attend:

City:    

If no membership, give church preference:

Name of Child's Doctor:

Doctor's Phone #:   

Person authorized to act for parents in case of an emergency:

Emergency Contact Phone #:   

Work Phone #:   

Address:

Check if your child has had any of the following:

Check if your child has had any evidence of the following:
Hearing loss or difficulties
Vision difficulties
Speech disabilities

Are there any special hospitalizations, operations, or other illnesses that we should be aware of?   
Yes   No

If yes, please list below.

Please indicate any family situations you feel are necessary for us to know
(ex. Are both parents living? Are you a single parent? Is there someone
that is not allowed to pick up your child?)

Your child may be released to the following people:

Name:   
Relationship:  

Name:   
Relationship:  

Name:   
Relationship:  

**Registration fee is non-refundable.

In order to submit this form, you must fill out the image challenge below.
There are two words and must be input with a space in between the words.