LAKESIDE BAPTIST WEEKDAY EDUCATION

LAKESIDE BAPTIST WEEKDAY EDUCATION
Session*
DATE*

MonthDayYear
Date
Name of Child*
Birthdate*

MonthDayYear
Date
Gender

BoyGirl
E mail address
example@example.com
Phone Number
Please choose your child's class based on the age they would be September 1st of the school year you are applying for.
6-12 months

MondayTuesdayWednesdayThursdayFriday
12-23 months

MondayTuesdayWednesdayThursdayFriday
Twos

5-days - Monday - Friday3-days - Monday, Wednesday, Friday2-days - Tuesday, Thursday
3K

5-days - Monday - Friday3-days - Monday, Wednesday, Friday
4K

5-days - Monday - Friday4-days - Monday, Wednesday, Thursday, Friday
Signature of parent / guardian

Clear
Printed name of parent / guardian
Do you have a child presently enrolled in the program?

YesNo
Church you attend or religious preference
List the ways you expect our program to help your child
How did you hear about our program?
Please check the one filling out this form

ParentGuardian
Mother's Name
Home Phone
Mother's E mail address
example@example.com
Mother's Employer
Please check one

I check my e-mail regularlyI don't check my e-mail regularly, please send information by mail
Mother's Cell Phone
Mother's Business Phone
Address
City
State
Zip
Father's Name
Home Phone
Father's E mail Address
example@example.com
Father's Employer
Father's Cell Phone
Father's Business Phone
Address
City
State
Zip
Child lives with
Mom's cell carrier
Dad's cell carrier
Person responsible for paying the bill
SS# of the payer
Does this child have any physical or emotional problems which require special medication or would be helpful for the staff to know.
If yes, please give a brief explanation
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, fevers, nervousness, temper tantrums, etc.
Should be Empty: