Preschool Participant Information Form

Preschool Participant Information Form
Child's Name

First NameLast Name
Year
Age
Choose your Class:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email Address:
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Father's Name

First NameLast Name
Father's Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Cellphone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Name

First NameLast Name
Mother's Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Cellphone Number
Please enter a valid phone number.Format: (000) 000-0000.
The Huntley Park District welcomes individuals with disabilities into the program. Please describe any accommodation needed for successful inclusion into the program.
Medical Allergies, Illness, or Other:
Primary Language at Home:
Emergency Information:
Emergency Contact #1

First NameLast Name
Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2

First NameLast Name
Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's Headshot
Pickup Authorization:
The following individuals are authorized to pick up my child (list all that apply)
Separate each name with a comma (,)
Parent Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Preschool Participant Information Form

Emergency Information:

Pickup Authorization: