Form
Preschool Registration Form
Siparia Open Bible Precious Jewels ELC
Child's Name
First Name
Last Name
Child's Age
Date of Birth
-
Day
-
Month
Year
Sex
Boy
Girl
Vaccine
Polio
Bcg
Small Pox
Diphtheria
Yellow Fever
Date/Term when you wish for child to begin
September Term 1
January Term 2
April Term 3
Is Child Potty Trained?
Yes
No
Partial
Address
*
Street Address
Street Address Line 2
City
Does child have any disability or special need? Please specify.
Mother's Name
First Name
Last Name
With whom does the child live?
*
Both Parents
Mother
Father
Guardian
Mother's Telephone Number
Please enter a valid phone number.
Email
example@example.com
Occupation
Father's Name
First Name
Last Name
Father's Telephone Number
Please enter a valid phone number.
Occupation
Email
example@example.com
In case of emergency contact name
First Name
Last Name
Relationship to child
Phone Number
Please enter a valid phone number.
Please upload a copy of child's birth certificate, immunization Card, ID of mother, father, guardian (where applicable) and emergency person.
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