LAKESIDE BAPTIST WEEKDAY EDUCATION

LAKESIDE BAPTIST WEEKDAY EDUCATION
2021-22 REGISTRATION
DATE:

Month Day Year
Date
Name of Child
Birthdate

Month Day Year
Date
Boy Girl
Parent Phone
Please enter a valid phone number.
E mail address
example@example.com
Please choose the class based on their age on September 1st of 2021
6-12 months

Mon Tue Wed Thur Fri
12-23 months

Mon Tue Wed Thur Fri
Twos

Mon-Fri Mon, Wed, Fri Tue, Thur
3K

Mon-Fri Mon, Wed, Fri
4K

Mon-Fri Mon, Wed, Thur, Fri
Signature of parent / guardian

Clear
Is your child presently enrolled in the program?

Yes No
Church you attend or religious preference
List the ways you expect our program to help your child
How did you hear about our program?
Mother's name
Parent or Guardian

Parent Guardian
Home phone
Please enter a valid phone number.
E-mail

I check my e-mail regularly I don’t check my e-mail regularly, please send information by mail
Mother's E mail address
example@example.com
Mothers cell phone
Please enter a valid phone number.
Employer
Mother's work phone
Please enter a valid phone number.
Street Address
City
State
Zip Code
Father's Name
Father's E mail Address
example@example.com
Father's Phone
Please enter a valid phone number.
Employer
Father's work phone
Please enter a valid phone number.
Address (type "same" if same as mother)
City
State
Zip
Child lives with
Person responsible for paying the bill
SS#
MEDICAL INFORMATION
Does your child have any physical or emotional problems which require special medication?
If yes, describe here
Known allergies
Allergic to medicines?
Communicable diseases your child has already had
List below any additional comments as to special problems of your child, e.g., throat/ear problems, nervousness, temper tantrums, etc.
Should be Empty:

LAKESIDE BAPTIST WEEKDAY EDUCATION

2021-22 REGISTRATION

MEDICAL INFORMATION