Preschool Registration

Preschool

Registration

Name of Child Care Center

Child's Information

First name

Last name

M.I.

DOB

Street address

Street address line 2

City

State

Zip code

Male or female?

Hours of child care required (school hours are 6:30 am to 6:00 pm)

Other

Days of the week required (minimum 2 days)

Do you require before or after school care?

What school does your child attend?

What grade is your child in?

Parent's Information

Parent's/Guardian's name

Phone number

Place of work

Phone number

Email address

example@example.com

Emergency Contact 1
In the event of an emergency, please contact:

First name

Last name

Primary phone number

Secondary phone number

Emergency Contact 2
In the event of an emergency, please contact:

First name

Last name

Primary phone number

Secondary phone number

Other people authorized to pick up your child from school

First name

Last name

First name

Last name

Medical information

Doctor

Doctor's phone number

Dentist

Dentist's phone number

Preferred hospital

Insurance/health coverage

Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.