Preschool Participant Information Form

Preschool Participant Information Form
Child's Name*

First NameLast Name
Year*
Age*
3 Year-old Preschool4 Year-old PreschoolMixed-Age PreschoolDual Language PreschoolNight Owl Preschool
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email Address:*
example@example.com
Date of Birth*

MonthDayYear
Date
MaleFemale
Father's Name*

First NameLast Name
Father's Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Cellphone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Name*

First NameLast Name
Mother's Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Cellphone Number*
Please enter a valid phone number.Format: (000) 000-0000.
The Huntley Park District welcomes individuals with disabilities into the program. Please describe any accommodation needed for successful inclusion into the program.
Medical Allergies, Illness, or Other:
Primary Language at Home:
Emergency Information:
Emergency Contact #1*

First NameLast Name
Emergency Contact #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2*

First NameLast Name
Emergency Contact #2 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Child's Headshot*
Pickup Authorization:
The following individuals are authorized to pick up my child (list all that apply)*
Separate each name with a comma (,)
Parent Signature*
Date

MonthDayYear
Date
Should be Empty:

Preschool Participant Information Form

Emergency Information:

Pickup Authorization: