Prospect Presbyterian Preschool 2009/2010 Enrollment Agreement
Name of Child ______M ___F ______ (Nickname)
Address ______
Number and Street City State Zip P.O. Box
Home Phone ______Age ______Date of Birth ______
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Class Enrolling In ______Reg. Fee Paid ______Date ______
1st Choice Days ______2nd Choice Days ______
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Family Information
Mother’s Name ______Home Phone ______
Employer ______Business Phone ______
Occupation ______Cell Phone ______
Father’s Name______Home Phone ______
Employer ______Business Phone ______
Occupation ______Cell Phone ______
Parents Marital Status Married ___ Divorced ___ Separated ____ Remarried ______
Sibling(s): Name / Age
1. ______3. ______
2. ______4. ______
Other Adults in the Home ______Relationship ______
Pets ______
Church Membership ______
Pick Up Authorization
Names and phone numbers of persons to whom we may release your child:
Name/Relationship Phone Number
1. ______
2. ______
3. ______
Do you carpool? ______
Drivers Phone Number
1. ______
2. ______
3. ______
(OVER)
Child’s Information
Has your child attended preschool previously? ______Where? ______
Favorite activities and toys ______
Does your child have any known allergies (such as dust, medications, plants, animals, food, etc.)? If yes, what are they? (Be specific) ______
______
Please give any information concerning your child which will be helpful in his / her experience (playing, eating, special fears, special likes or dislikes). ______
______
______
Emergency Care Information
Name of Child’s Doctor ______Office Phone ______
Office Address ______
Insurance Company ______Policy No ______
Name of Child’s Dentist ______Office Phone ______
Office Address ______
Hospital Preference ______
If father, mother, (or guardian) cannot be contacted, call:
Name / Relationship Phone Number
1. ______
2. ______
3. ______
I agree that the Director/Teacher may authorize the physician of his/her choice to provide emergency care in the event that neither the family physician nor I can be contacted immediately.
I WILL PROVIDE MY CHILD’S IMMUNIZATION RECORD BY SEPTEMBER 1.
Parent’s Signature ______Date ______