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Preschool Enrollment Form

Please complete the form below. Required fields marked with an asterisk *

Date of Enrollment (Start Date)*

Answer Required

CHILD INFORMATION

Child's Name (First and Last)*

Answer Required

Street Address, City, State, Zip*

Answer Required

Child's Date of Birth:*

Answer Required

Primary Language:*

Answer Required

Child's Schedule*

Answer Required

Monday

Tuesday

Wednesday

Thursday

Friday

PARENT/GUARDIAN #1 INFORMATION

Parent/Guardian #1 First and Last Name:*

Answer Required

Primary Phone Number*

Number Required

Street Address, City, State, Zip*

Answer Required

Email address*

Answer Required

Special instructions for how to reach this parent/guardian while child is at the preschool*

Answer Required

Parent/Guardian #1 Business Name:

Answer Required

Business Phone Number

Number Required

Street Address, City, State, Zip

Answer Required

Email Address:

Answer Required

PARENT/GUARDIAN #2 INFORMATION

Parent/Guardian# 2 First and Last Name:

Answer Required

Primary Phone Number

Number Required

Street Address, City, State, Zip

Answer Required

Email Address:

Answer Required

Special instructions on how to reach this parent/guardian while the child is at the preschool

Answer Required

Parent/Guardian #2 Business Name:

Answer Required

Business Phone Number:

Number Required

Street Address, City, State, Zip

Answer Required

Email Address

Answer Required

MEDICAL INFORMATION

Identified Allergies*

Answer Required

Identified Marks:

Answer Required

Health Insurance Provider: Group Number, Phone Number

Answer Required

Name of Physician:*

Answer Required

Physician Phone Number*

Answer Required

Physician Street Address, City, State, Zip*

Answer Required

Date of Child's Last Physical*

Answer Required

Name of Dentist*

Answer Required

Dentist Phone Number*

Answer Required

Dentist Street Address, City, State, Zip*

Answer Required

Name of hospital of choice (In case of an emergency needing immediate medical care)*

Answer Required

Hospital Phone Number*

Answer Required

Hospital street address, City, State, Zip*

Answer Required

EMERGENCY CONTACTS

MUST list at least one emergency contact (18+ years old) other than parent or guardian listed above

Name (First and Last) of Emergency Contact #1*

Answer Required

Phone Number *

Answer Required

Street Address, City, State, Zip*

Answer Required

Email*

Answer Required

Name (First and Last) of Emergency contact #2

Answer Required

Phone Number

Answer Required

Street Address, City, State, Zip

Answer Required

AUTHORIZATION FOR PICK-UP PERSON(S)

I understand that any person(s) I list below will be authorized to pick-up my child at anytime with NO additional written and/or verbal authorization. I also understand that it is my responsibility to make any and all changes as they arise.

Name (First and Last) of authorized pick-up person #1 *

Answer Required

Phone Number*

Answer Required

Street Address, City, State, Zip*

Answer Required

Email*

Answer Required

Name (First and Last) of authorized person #2

Answer Required

Phone Number

Answer Required

Street Address, City, State, Zip

Answer Required

By signing below I am acknowledging that I have read, understand, and agree to all of the above information as listed in the Enrollment Forms.

ONLY ONE SIGNATURE NEEDED BELOW

Parent 1 Signature:*

Answer Required

Today's Date:*

Answer Required

Parent 2 Signature

Answer Required

Today's Date

Answer Required