Perry Prep Enrollment Form

Enrollment Form

Perry Prep Learning Center
Entrance Date*

MonthDayYear
Date
Withdrawal Date*

MonthDayYear
Date
Child's Name*

First NameMiddle NameLast Name
Sex*

MaleFemale
Child's Age*
Child's Date of Birth*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Father's Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Father’s Home Address (if different from child’s):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father’s Place of Employment:
Work Phone:
Please enter a valid phone number.
Employer’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother’s Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Mother’s Home Address (if different from child’s):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother’s Place of Employment:
Work Phone:
Please enter a valid phone number.
Employer’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child’s Living Arrangements: (check one)*

Both ParentsMotherFatherOther
Child’s Legal Guardian(s): (check one)*

Both ParentsMotherFatherOther
Is your child currently enrolled in another daycare or preschool?*
Is your child completely potty trained?*

YesNo
Is your child currently receiving speech therapy services?*
Does your child require special services we should know about?*
The child may be released to the person(s) signing this agreement or to the following:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to child
Relationship to Parent(s) or Guardian
Other identifying information (if any)
Persons to contact in the case of emergency when parent or guardian cannot be reached:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name of Public or Private School child attends, if any:
Child’s doctor or clinic name:
Doctor/clinic phone number:
My child has the following special needs:
The following special accommodation(s) may be required to effectively meet my child’s needs while at the center:
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns:
I certify that all information above is correct.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: