Name of child  ________________________________________________________

Address  ______________________________________________________________

Telephone number  __________________   Date of birth  _________________

Mother's name and occupation  _________________________________________

Father's name and occupation  _________________________________________

Marital status of parents  ____________________________________________

Other adults at home  _________________________________________________

Relationship to child  ________________________________________________

Names and ages of other brothers and sisters  _________________________

If child is accustomed to a nickname, please list  ____________________

Name and location of church now attending  ____________________________

Mother's employer's address and phone number  _________________________

Father's employer's address and phone number  _________________________

Emergency care (other than parents):

Name  _________________________  Address  _____________________________

Phone  _________________________  Relationship  _______________________

Persons allowed to pick up the child (include parents if applicable):

_______________________________________________________________________

Mother's signature ____________________________________________________

Father's signature ____________________________________________________

Pediatrician's name and phone number  _________________________________

Dentist's name and phone number  ______________________________________

Allergies  ____________________________________________________________

Other medical or physical limitations  ________________________________

Is the child taking any medications?  _________________________________

Describe your child's sleeping habits (nap, bedtime....) ______________

 ______________________________________________________________________

Does your child dress independently?  _________________________________

Does your child use the bathroom independently?  ______________________

What method of discipline have you found most effective?  _____________

How does your child respond to correction?  ___________________________

Does the child have any fears that we should be aware of?  ____________

_______________________________________________________________________

Family and play information:

List the activities that your child enjoys  ___________________________

Does your child play with other children?  ____________________________

Does your child usually play alone?  __________________________________

What would you like your child to gain from the preschool experience? 

_______________________________________________________________________

As parents, list your special interests and/or talents that could be shared with us this year?

_______________________________________________________________________

The registration fee is $50.oo which includes a preschool shirt.

Please indicate size _______

Please indicate your session preference, please read carefully!

____ Tuesday/Thursday 3 year old program AM - $85.00 per month

____ Monday/Tuesday/Thursday 4 year old program AM - $105.00 per month