Registration 2016-2017
Child's Full Name
Date of birth:
Current Age
Gender
Mothers Name:
Fathers Name
Street Address:
CIty:
State
Home Phone #:
E-Mail Address:
Mother's Work #:
Mother's Cell:
Father's Work #
Father's Cell:
Emergency Contacts:
In the event of an emergency, if parents are not available, please contact:
# 1
Name:
Relationship to child:
Phone number:
#2
Name:
Relationship to child:
Phone number:
Special Needs:
Please list any of your child's special needs; physical, dietary or allergies for example:
Please enroll my child for the following days:
Monday
Tuesday
Wednesday
Thursday
Friday
Monthly tuition rates: 2 days per week: $143.00;  3 days per week: $186.00;
4 days per week: $246.00;  5 days per week: $302.00
Dismissal: Permission for pick-up

The following individuals have permission to pick up my child:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Must show picture identifiation.
Photo Release:
I,
the parent/legal guardian of
give permission for my child's photo to
be taken for use by the The Preschool.  I understand that the photo may be displayed at the school, used in a slide show for the church, or shown on our website.
Signature of parent or guardian:
Date:
Click for new image
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