Parkwood Weekday Early Education (WEE) Center

2013-14 Information Form

(Due June 10, 2013)

Child’s Full Name (Last, First, MI):
Nickname: / Sex (Circle): Male Female / Child’s Date of Birth:
Does Child Live With Both Parents? Yes NO / If No, Which Parent does Child Reside With?
Child’s Street Address:
City: / State: / Zip Code:
Mom’s Name (Last, First): / Mom’s Email:
Mom’s Address (If different from child):
Mom’s Home Phone: / Mom’s Cell Phone:
Mom’s Work Phone: / Occupation:
Place of Employment (Name & Address):
Dad’s Name (Last, First): / Dad’s Email:
Dad’s Address (If different from Child):
Dad’s Home Phone: (If different): / Dad’s Cell Phone:
Dad’s Work Phone: / Occupation:
Place of Employment (Name & Address):
Marital Status: / Guardian/Custodial Parent:
Special Custodial/Visitation Restrictions That Apply to School Drop-off/Pick-up:
Does Your Child Speak English?: Yes No / What Language is Spoken Most at Home?
Family Church Affiliation:

EMERGENCY CONTACT LIST

If a parent cannot be reached, please list in order at least 3 family or friends you want us to call in case of emergency, illness or other issue regarding your child. These persons are authorized to pick up your child. All unfamiliar persons will be required to show a government-issued, picture I.D.

Name: / Phone: / Relationship
Name: / Phone: / Relationship:
Name: / Phone: / Relationship:
Name: / Phone: / Relationship:

MEDICAL EDUCATIONAL INFORMATION:

Child’s Doctor: / Phone:
Date of child’s last physical:
Does your child have food allergies (please circle)? Yes No
If yes, please list and explain reaction:
Does your child have any dietary restrictions? Yes No
If yes, please explain
Does your child have environmental allergies (please circle)? Yes No
If yes, please list and explain:
Does your child have any other medical conditions that our staff should be aware of?
Will your child require medication during school hours (please circle)? Yes No
Please list any medications that will be kept at school:
**PLEASE NOTE THAT A MEDICATION ADMINISTRATION PERMISSION FORM MUST BE COMPLETED AND SUBMITTED BEFORE ANY MEDICATIONS CAN BE KEPT AT THE SCHOOL
Does your child have any special educational needs? Yes No
Please explain:
Are there any other special concerns we should be aware of that will improve our ability to care for your child?
Has your child attended pre-school before? Yes No
If so, where and when did they attend?
Signature: / Printed Name: / Date:

**With my signature, I acknowledge that all information is accurate.