Preschool Registration Form - Design 3



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


Has your child completed all required immunization?
Yes
No






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