Ford's Chapel Learning Center Registration Form

Preschool Enrollment Form

Child's Information
Child's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Home Phone *
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMale

Parents/Guardian & Emergency Contact Information
Child's Legal Guardian:*

Both parentsMotherFatherOther
Name*

First NameLast Name
Email
example@example.com
Relationship
Mother, Father, etc
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Address

Same with the childDifferent Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Address

Same with the childDifferent Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Party Responsible for Payment of Tuition
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Emergency Contact 1*

First NameLast NameRelationship
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Emergency Contact 2

First NameLast NameRelationship
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.

Additional Questions:
Is your child toilet trained? Describe any assistance needed and words used:
Is any language other than English used in the home? If so, please list:
Are there any special medical, physical, or emotional needs that the school or staff should be aware of?
Does your child receive any special services that the school should be aware of?
Do you want to add something?
Marital status of parents, medical information, people who the child cannot be released, etc
Release of Liability
I hereby release Ford’s Chapel United Methodist Church (FCUMC) and Ford’s Chapel Learning Center (FCLC) program from any liability for accidents or injuries that may occur to my child while on the premises or during scheduled field trips. In the event of an emergency, I grant permission for staff or teachers to contact the designated physician or seek appropriate medical care for my child if I am unavailable. I also agree to assume responsibility for any medical expenses incurred as a result of such treatment.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Signature*

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