Registration Form

Applying for ___ 3 Year Old (3 day) ____ 3 Year Old (5 day) ____ 4 Year Old (3 day) ____ 4 Year Old (5 day)

To enroll in the Three Year Program the child must be 3 by September 10^th ALL CHILDREN MUST BE TOILET

To enroll in the Four Year Program the child must be 4 by September 10^th TRAINED TO ATTEND PRESCHOOL

General Information

Name of Child: _________________________ Name Used at Home____________________

Birthdate: __/__/__ Present Age ______ Sex: ___M ___F Phone Number _______________

Address________________________________________________________________________

E-MAIL ADDRESS:_______________________________________________

Parents are: Married____ Separated____ Divorced ____ Adoptive Parent ____ Grandparent____

Names of other children in family:

Name: __________________________________________ Birthdate: __/__/__

Name: _________________________________________ Birthdate: __/__/__

Full name of Mother:_________________________________________ Cell Phone:_________________

Address:_________________________________________________ Home Phone:__________________

Place of work:_____________________ Address:_____________________ Work Phone:_____________

Full name of Father:_________________________________________ Cell Phone:_________________

Address:_________________________________________________ Home Phone:__________________

Place of work:_____________________ Address:_____________________ Work Phone:_____________

Church you attend: ______________________ If nonmember, give church preference_______________