(PARENT AND OR GUARDIAN) DUMC Preschool Registration Form

REGISTRATION FORM
DUNLAP UNITED METHODIST PRESCHOOL
23674 US 33 EAST
ELKHART, INDIANA 46517
PHONE 574-875-7950
First
Name Child goes by
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Phone
Date of Birth

MonthDayYear
Date
FAMILY BACKGROUND
(PARENT AND OR GUARDIAN)
Father
Mother
Employer
Employer
Work phone
Work phone
Mother
Father
Other
LIVING
DECEASED
REMARRIED
BROTHERS
Person responsible for caring for my child during the day
Name
Phone
IN CASE OF AN EMERGENCY. LIST TWO PERSONS 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 If you were not referred: how did you hear about 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 lows that it is my responsibility to transport, orfind responsible transportation, to and from all field trips. I further understand that my child will not leave the school premises with out my knowledge. Signature of Porent/Guardian
Signature of Porent/Guardian

Clear
Date

MonthDayYear
Date
3 Year Old Classes (child must be 3 by August 1st)

3 year old (Monday, Tuesday, Thursday & Friday)
4 Year Old Classes (child must be 4 by August 1st)

4 year old (Monday, Tuesday, Thursday, Friday)
HEALTH
Phone
RECORDS
Medical History (indicate yes or no)
Asthma
Bronchitis
Mumps
Chicken Pox
Pneumonia
Diabetes
Red Measles
Tonsillitis
Scarlet Fever
Other
Does your child have: Allergies Hearing Loss Hemophilia Seizure Disorder
Allergies
Explain
Hearing Loss
Explain
Hemophilia
Explain
Seizure Disorder
Explain
Speech Disorder
Explain
Other
Aphysical exom is NOT necessary for admission: however, a copy of your child's birth certificate and current immunization records are required for entrance in 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 mode to contact a parent, the child's physician, or other persons listed for emergency notification
Signature of Porent/Guardian

Clear
Date

MonthDayYear
Date
E mail
example@example.com
Should be Empty:

REGISTRATION FORM

DUNLAP UNITED METHODIST PRESCHOOL

23674 US 33 EAST

ELKHART, INDIANA 46517

PHONE 574-875-7950

FAMILY BACKGROUND

(PARENT AND OR GUARDIAN)

LIVING

DECEASED

REMARRIED

BROTHERS

RECORDS