LIL BUFFS PRESCHOOL ENROLLMENT FORM
Name (Last, First, MiddleHome – Physical Address
Home – Mailing Address
City, State, Zip
Home Phone
Mother’s Contact Information
Mother (last, first)
Mother’s Home Phone
Mother’s Cell Phone
Mother’s Employer
Mother’s Work Phone
Mother’s Email
Father’s Contact Information
Father (last, first)
Father’s Home Phone
Father’s Cell Phone
Father’s Employer
Father’s Work Phone
Father’s Email
Student’s Information
Student Cell Phone
Date of Birth
Gender / 0 Female 0 Male
Grade Level – Circle Grade / PK, K, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12
Ethnicity – Check One / Is the student Hispanic or Latino?
0 Yes 0 No
Race / 0 (AM) American Indian or Alaska Native
Check all that apply: / 0 (AS) Asian
0 (BL) Black or African American
0 (PI) Native Hawaiian/Other Pac Islander
0 (WH) White
Student Lives with: 0 Mother/Father 0 Mother 0 Father 0Mother/Step Father
0 Father/Step Mother 0 Guardian 0 Self 0Other
Please check any program(s) in which the student is currently in:
0 Resource 0 Chapter Reading 0 Chapter Math 0 Speech 0 504 Plan
Other Significant Data (i.e. asthma)______
Has your child previously attended a preschool program? 0 Yes 0 No
Name of previous program______
Does your child have an individual education program (IEP)? 0 Yes 0 No
What was your child’s weight at birth? ______
Was your child born prematurely? 0 Yes 0 No How early? ______
Were/are you a teen parent? 0 Yes 0 No
Brothers Name Date of Birth Sisters Name Date of Birth
______
______
______
Emergency Contact #1______
Other than Parent Name Relationship Phone Number
Emergency Contact #2______
Other than Parent Name Relationship Phone Number
Doctor______
Name Phone Number
Residing County – Check One 0 BUFFALO 0 DAWSON 0 PHELPS
Resident of Elm Creek – Check One 0 Yes 0 No 0 Option Student
Signature:______Date:______
(Parent/Guardian/Foster Parent)