PRESCHOOL REGISTRATION FORM
1477 South Schodack Rd. Castleton, NY 12033 (518)477-7103
CHILD INFORMATION:
Name:
*
First Name
Last Name
Nick name:
Telephone:
Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
My child will attend: (Please Select Session)
*
Session I: Tuesday, Thursday
Session II: Monday, Wednesday, Friday
Session III: Monday through Friday
Timings: (Please Select Timing)
*
Before Care : 7:00AM - 9:00AM
After Care: 2:00PM - 5:00PM
Preschool: 9:00AM - 2:00PM
Full Day: 7:00AM - 5:00PM
Address:
*
Street
Apt.
City:
*
State:
*
Zip:
*
Date of Birth:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Last Medical Exam:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Allergies: (Please be specific):
If none, please enter N/A
Pediatrician:
If none, please enter N/A
Developmental Concerns:
If none, please enter N/A
PARENT INFORMATION:
Mother:
First Name
Last Name
Father:
First Name
Last Name
Indicate if different than the child
Telephone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMERGENCY INFORMATION:
Mother
Daytime Location
Daytime Phone
Cell Phone
Father
Daytime Location
Daytime Phone
Cell Phone
Emergency Contact Person:
*
Relationship to Child
*
Telephone
*
Parent’s Signature:
Signature
*
Please verify that you are human
*
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