Enrollment Information Form

ENROLLMENT INFORMATION FORM
Date of Registration

MonthDayYear
Date
CHILD INFORMATION
Name of Child (Last, First, Middle Initial)
Nickname
Age
Sex
Date of Birth

MonthDayYear
Date
Child's Primary Language
Parent/Guardian's Primary Language
Home Phone
Home Email Address
example@example.com
Child's Home Address
Primary Residence

MotherFatherBothGuardian
Preschool Class

Full time DaysPart Time Days
Infant Class

Full time DaysPart time Days
School Age (Kindergarten)

Full time DaysPart time DaysBoth
Days to Attend

Monday AMTuesday AMWednesday AMThursday AMFriday PMMonday PMTuesday PMWednesday PMThursday PMFriday PM
AM Arrival Time
AM Departure Time
PM Arrival Time
PM Departure Time
PRIMARY CONTACT AND RELEASE PERSONS
Parent/Guardian #1
Relationship to Child
Home Phone
Cell Phone
Home address
Email
example@example.com
Driver's License Number/State
Employer
Employer's Address
Work Phone Number
Please enter a valid phone number.
Work Hours
PRIMARY CONTACT AND RELEASE PERSONS
Parent/ Guardian #2

First NameLast Name
Relationship to Child
Home Phone
Cell Phone
Home Address
Email
example@example.com
Driver's License Number/State
Employer
Employer's Address
Work Phone Number
Please enter a valid phone number.
Work Hours
Parent/Guardian Signature

Clear
ENROLLMENT INFORMATION FORM
Name of Child
Date of Birth

MonthDayYear
Date
EMERGENCY CONTACT AND RELEASE PERSONS

Please list the persons you would like contacted (in order of priority) if you cannot be reached in case of emergency. Check the "Emergency Contact and Release" box, as the persons listed will also be authorized to pick up or accompany the child for the purposes of medical treatment. We will not release a child to anyone (other than the parent) under the age of eighteen (18 including siblings. Additionally, please list the persons you would like to be authorized for pick-up only on a given day (i.e., babysitter For these persons, check the "Release Only" box. For the safety of your child, we will request all authorized release persons with whom staff are not familiar to provide government- issued photo identification at the time of pick-up.
Name #1
Relationship to Child
Primary Phone
Secondary Phone
Home Address
Work Phone/Extension
Name
Relationship to Child
Primary Phone
Secondary Phone
Home Address
Work Phone/Extension
Name
Relationship to Child
Primary Phone
Secondary Phone
Home Address
Work Phone/Extension
Please choose one

Emergency Contact and ReleaseRelease Only
If you want a person who is not identified above to pick up your child, you must notify school staff in advance, in writing. Your child will not be released without prior authorization. In the event you call a pick-up authorization into the school because you are unable to submit your authorization in writing, we will use your personal information from this packet to verify your identity.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Date of Termination

MonthDayYear
Date
Parent Updates

(Only fill this out if requested by the office)
(Signature)

Clear
(Date)

MonthDayYear
Date
(Signature)

Clear
(Signature)

Clear
Should be Empty:

ENROLLMENT INFORMATION FORM

CHILD INFORMATION

ENROLLMENT INFORMATION FORM

Parent Updates