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?
Has your child completed all required immunization?
Please list immunizations that have NOT been administered to your child.
Do you permit 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