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
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.Format: (000) 000-0000.
Email*
example@example.com
Father's Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Employer’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Both ParentsMotherFatherOther
Both ParentsMotherFatherOther
Is your child currently enrolled in another daycare or preschool?*
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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: