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?

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

Half-day morning 9:00am-12:00pm Half-day with meals 8:30am-12:30m Full Day 4 hours or more
Days of the week required (minimum 2 days)

Monday Tuesday Wednesday Thursday Friday
Do you require before or after school care?

Before school After school
What school does your child attend?
What grade is your child in?
Parent's Information
Parent's/Guardian's name
Parent's/Guardian's name
Phone number
Phone number
Place of work
Place of work
Phone number
Phone number
Email address
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.
Should be Empty:

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