DUMC Preschool Registration Form

DUNLAP UNITED METHODIST PRESCHOOL

23674 US 33 E // Elkhart, IN 46517 // (574) 875-7950
BASIC INFORMATION
Child's Full Name (First Middle Last)
Name Child goes by
Address

Street Address

Street Address Line 2

City

Zip Code
Phone
Date of Birth

Month Day Year
Date
Sex
FAMILY BACKGROUND

Parent and/or Guardian
Father/Guardian
Mother/Guardian
Father's Employer
Father's Work phone
Mother's Employer
Mother's Work phone
Child Resides With:

Select one by marking "x"
Both parents
Mother
Father
Other
Concerning the parents:
Is the Father living?
Is the Father deceased?
Is the Father remarried?
Is the Mother living?
Is the Mother deceased?
Is the Mother remarried?
Siblings:

Please include ages
Brothers
Sisters
Person Responsible For Caring For My Child During The Day:
Name
Phone
In Case Of Emergency

Please list TWO people who should be called
Name
Relationship
Phone
Name
Relationship
Phone
Name of the church where your family attends
Did someone refer you to us?YesorNo
Did Someone Refer You To Us?

Please choose one with an "x"
Yes
No
If yes, by who?
If you were not referred to us, how did you hear about us?
Where will your child attend Kindergarten?
I hereby register my child in the Dunlap United Methodist Preschool. Included with this enrollment form is the NON-REFUNDABLE registration fee. I understand due to current seatbelt laws that it is my responsibility to transport or find responsible transportation, to and from all field trips. I further understand that my child will not leave the school premises without my knowledge.
Signature of Parent/Guardian

Clear
Date

Month Day Year
Date
Class Selection
3 Year Old Class (child must be 3 by August 1st)
4 Year Old Class (child must be 4 by August 1st)
Health Information
Name of child's physician
Physician's Phone Number
Medical History

Indicate if they have/have had the follow by answering YES or NO.
Asthma
Bronchitis
Chicken Pox
Mumps
Pneumonia
Red Measles
Diabetes
Tonsillitis
Scarlet Fever
Other
Does your child have...

Answer Yes or No. Please explain each Yes answer.
Allergies
Explain (allergies)
Hearing Loss
Explain (hearing loss)
Hemophilia
Explain (hemophilia)
Seizure Disorder
Explain (seizure disorder)
Speech Disorder
Explain (speech disorder)
Other
A physical exam is NOT necessary for admission; however, a copy of your child's Birth Certificate and current Immunization Records are required for entrance into our preschool.
In the event of illness or accident which requires immediate medical treatment at a time when a parent/guardian cannot be located, I give permission for the Dunlap United Methodist Preschool to provide such emergency treatment to the best of their knowledge and ability. I will not hold the school or medical personnel responsible. This is to be done with the understanding that every attempt has been made to contact a parent, the child's physician, or other persons listed for emergency notification.
Signature of Parent/Guardian

Clear
Date

Month Day Year
Date
E mail
example@example.com
Should be Empty:

DUNLAP UNITED METHODIST PRESCHOOL

BASIC INFORMATION

FAMILY BACKGROUND

Child Resides With:

Concerning the parents:

Siblings:

Person Responsible For Caring For My Child During The Day:

In Case Of Emergency

Did Someone Refer You To Us?

Class Selection

Health Information

Medical History

Does your child have...