Fifth Avenue Baptist Nursery and Preschool
1135 5th Avenue
Huntington, WV 25701
P: (304)525.5441
F: (304)697.8469
Wait List Form
Please fill out completely
Child's Information:
Child's Name:
First Name
Last Name
Birthday:
-
Month
-
Day
Year
Date
Complete Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Schedule of Days:
Schedule of Hours:
*Known Allergies:
*
*History of serious illness or injury?
*
*Recent Stressful Experience?
*
*Please use the back of this form if you need to share more details.
Baby Information:
Due Date:
-
Month
-
Day
Year
Date
Expecting Start Date:
-
Month
-
Day
Year
Date
*Please be mindful that FAB will make attempts to accommodate your expecting start date, but we cannot make any promises that it will happen.
Parent/Guardian Information:
Name:
First Name
Last Name
Email:
example@example.com
Primary Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Employer:
Work Address:
Parent/Guardian Information:
Name:
First Name
Last Name
Email:
example@example.com
Primary Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Employer:
Work Address:
Any Special Information: (custody agreement, foster care agreement)
Signature of Parent/Guardian:
Date:
-
Month
-
Day
Year
Date
Office Use Only:
Date Filled:
-
Month
-
Day
Year
Date
Office Use Only:
Date Enrolled:
-
Month
-
Day
Year
Date
Notes:
Orientation Date:
-
Month
-
Day
Year
Date
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