| Child's Name: |
|
| Birthdate: |
(mm/dd/yyyy) |
| Sex: |
|
| Home Phone: |
(include area code) |
| Home Address: |
(street address, city, zip) |
| Your email address: |
(required for registration) |
| |
| Child lives with: mother father both parents other |
| If child does not live with both parents, please provide address & phone number of other parent: |
| Alt Phone: |
(include area code) |
| Alt Address: |
(street address, city, zip) |
| |
| Mother's Name: |
|
| Mother's Email: |
|
| Occupation: |
|
| Name of Employer: |
|
| Work Phone: |
(include area code) |
| Employer's Address: |
(street address, city, zip) |
| Mother's Cell Phone: |
(include area code) |
| |
| Father's Name: |
|
| Father's Email: |
|
| Occupation: |
|
| Name of Employer: |
|
| Work Phone: |
(include area code) |
| Employer's Address: |
(street address, city, zip) |
| Father's Cell Phone: |
(include area code) |
| |
| Please list siblings & their ages: |
|
| |
| Desired days and times to attend Sholom Preschool (as available in tuition schedule): |
|
|
In the event of an emergency, the following people should be contacted if parents are not available.
(THE STATE REQUIRES A MINIMUM OF 2 EMERGENCY CONTACTS - IF YOU DO NOT LIST AT LEAST TWO, THE POLICE DEPARTMENT AND THE STATE WILL BECOME YOUR EMERGENCY CONTACTS):
|
| 1st Contact Name: |
|
| Relationship: |
|
| Phone: |
(include area code) |
| 2nd Contact Name: |
|
| Relationship: |
|
| Phone: |
(include area code) |
| 3rd Contact Name: |
|
| Relationship: |
|
| Phone: |
(include area code) |
| 4th Contact Name: |
|
| Relationship: |
|
| Phone: |
(include area code) |
| |
Do we have permission to contact your doctor or dentist in an emergency?
yes no |
| Doctor: |
|
| Address: |
(street address, city, zip) |
| Phone: |
(include area code) |
| Dentist: |
|
| Address: |
(street address, city, zip) |
| Phone: |
(include area code) |
| |
| Does your child have any ongoing illness or health condition? |
|
| |
Does your child take any medication(s) on a regular basis?
yes no |
| Name of medication, frequency of dosage and amount given. |
|
| Name of prescribing physician: |
|
| |
Do you give your permission for the school to take your child to a hospital in an emergency when such action when advised by EMTs or hospital staff?
yes no |
| Hospital: |
|
| |
| What other schools has your child attended? |
(please include dates attended)
|
| |
| List any characteristics, or information you feel your child's teacher should know in order to provide the best care for your child: |
|
| |
| Name of person responsible for payment of tuition and other fees: |
|
| Address of responsible person: |
(street address, city, zip) |
| SS# of responsible person: |
|
|
| Indicate what you do want given to other parents for birthdays, etc: |
|
|
Directory Information
Please indicate your preference for listed in the school directory.
List child's name, address, and phone number
List child's name and phone only
List child's name and address only
List child's name only
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