Student Registration

Student Registration

2021-2022 School Year
Section 1:

Student Information
Student's Legal Name: *

First Name Last Name
What name do you call this child at home?
Birth Date *

Month Day Year
Date
Child's Address *
Is your child allergic to any foods?

Yes No
If yes, what food(s)?
Does your child have any dietary restrictions?

Yes No
If yes, what restriction(s)?
Does your child have any medical conditions that require him/her to have specialized treatment?

Yes No
If yes, what condition(s)?
Is there any information that you would like your child's teacher to know?
Section 2:

Family Information
Parent or Legal Guardian 1

First Name Last Name
Email Address
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Parent or Legal Guardian 2

First Name Last Name
Email Address
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number

Who lives in the same house as the student?

Name

Relationship to Student

In addition to the Parents/Guardians, who is authorized to pick up your child from school?

Name

Phone Number

Relationship

Section 3:

Videos or Photographs of your child may be taken during class. We will never publish or post a photo or video of your child without your written permission. Please let us know your preferences for your child's photos and videos.
Do you give permission for your child’s photo or video to be posted on the Preschool's website?

Yes No
Do you give permission for your child’s photo or video to be posted on Crossroads Community Church Facebook public page?

Yes No
Do you give permission for your child’s photo or video to be posted on the Preschool's Facebook private page?

Yes No
Do you give permission for your child’s photo or video to be used in written advertisements (pamphlets/flyers) for the school?

Yes No
Class Selection

Available Class times are subject to change based on enrollment.
Which Class would you prefer to have your child attend?
Signature

Clear
Today's Date

Month Day Year
Date
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Section 1: