Preschool Registration Form - Design 4


Child Name

Date of Birth

Sex
Male
Female

Home Address

City/State/Zip

Mother’s Name

Phone Number

Address

City/State/Zip

Father’s Name

Phone Number

Address

City/State/Zip

Does your child suffer from any allergies, illness, disability or other medical conditions? 
Yes
No

Please describe below. 
Has your child completed all required immunization?
Yes
No

Please list immunizations that have been administered to your child. 
Please list immunizations that have NOT been administered to your child. 

Do you permit your child to be immunized at school?
Yes
No

Please type your full name to give your consent for your child to be immunized at school: 
Please give reason: 

Is there any other information or issues you would like the teachers to know?

Please select preffered programs: 
2 days tuition a week
3 days tuition a week
4 days tuition a week
5 days tuition a week
before school care
after school care
before & after school care