First Name
Last Name
Preferred Name
Date of Birth
Gender
Home Address
City
State
Zip Code
Place of Birth
Nationality/Citizenship
Child's Photo
Does your child have any special needs, allergies, or medical conditions we should be aware of?
If yes, please describe in details
Has your child received any early intervention services?
If yes, please explain.
Does your child have any specific fears or anxieties? (e.g., loud noises, separate anxiety)
If yes, please describe in details
What are your child's strengths and interests?
What are some areas where your child might need extra support?
Language(s) spoken at home
First Name
Last Name
Phone Number
Email Address
Occupation
Employer
Relationship to Child
First Name
Last Name
Phone Number
Email Address
Occupation
Employer
Relationship to Child
First Name
Last Name
Phone Number
Email Address
Please enter.
Name | Relationship | |
|---|---|---|
Please enter.
Name | Relationship | |
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List the available programs.
Please specify your program preferences.
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
Preferred Start Date
Child's Physician Name
Phone Number
Clinic/Hospital
Insurance Company Name
Policy Number
Immunization Records
I/We acknowledge that I/we have received, read, and understand the [Preschool Name] Parent Handbook, which includes the Preschool's Policies and Procedures. I/We agree to comply with these policies and procedures.
Parent/Guardian Signature
Parent/Guardian Signature
I authorize the above-named individuals to be contacted in the event of a medical emergency involving me. I understand that this authorization allows healthcare providers to release my protected health information to these individuals for the purpose of facilitating my medical care and well-being. This includes, but is not limited to, information regarding my condition, treatment, and prognosis.
I understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken based on it.
Please sign here