ALDERSGATE PLAYSCHOOL
REGISTRATION FORM and EMERGENCY INFORMATION
CHILD’S FULL NAME_______________________________________________________________________
CLASS ENROLLING FOR______________Child’s Birth
Date_____________Nickname__________________
Parent’s
Name(s)_______________________________________________________________
Mailing Address_______________________________________________zip
code__________
Street Address (if different from
mailing)____________________________________________
Home Telephone__________________________Cell Phone
#___________________________
E-mail address:___________________________________Beeper #_______________________
Father’s
Employment_______________________________________Telephone_____________
Mother’s
Employment______________________________________Telephone_____________
Name and phone numbers of other contacts who will usually know
your whereabouts or can pick up the child in case the parent cannot be reached.
Name_____________________________________Name_______________________________
Relationship_______________________________Relationship__________________________
Telephone_________________________________
Telephone___________________________
ALLERGY TO FOOD OR
MATERIALS_________________________________________
In the event of an emergency all attempts will be made to
contact given emergency numbers. If
parents cannot be reached and medical treatment seems to be necessary,
authorization is given to obtain treatment.
Parent
Signature________________________________________________________
Child’s Physician/Phone
Number________________________________________________
Do you give permission for your child’s name, address and
phone number to be distributed to classmate parents? __________yes ___________no
When I register my child, I understand that a registration/insurance
fee of $45.00 ($25.00 for each
additional child) will accompany this form.
This fee is non-refundable. Registration fee will go up on June 1, 2013 to $ 55.00.
INDICATE DAYS DESIRED:
MON_____TUES_____WED_____THURS______FRI_____
(more information on other side)
FAMILY HISTORY
Other children in the family (at
home or away from home).
NAME AGE
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family Pets (Name and
Kind)______________________________________________________
Family Interests &
Hobbies_______________________________________________________
Special Fears of
Child____________________________________________________________
Favorite Play
Materials___________________________________________________________
Favorite
Activities_______________________________________________________________
Family church
preference_________________________________________________________
What expectations do you have for
your child at Playschool this year?_____________________
______________________________________________________________________________
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MEDICAL HISTORY
1.
Is child allergic to anything?
No_____Yes_____
If yes,
what?_____________________________________________________________
2.
Is child currently under a doctor’s care? No_____Yes_____
If yes, for what
reason?_____________________________________________________
3.
Is the child on any continuous medication? No____Yes____
If yes,
what?_____________________________________________________________
4.
Any previous hospitalizations or operations? No___Yes____
If yes, when and
what for?__________________________________________________
5.
Any history of significant previous diseases or recurrent illness? No____Yes_____
Diabetes No____Yes____; Seizures
No___Yes____; Heart Trouble
No____Yes____
6.
Does the child have any physical disabilities?: No_____ Yes_____
If yes, please
describe:_____________________________________________________
Parent’s
Signature_________________________________
We require proof of the child’s
immunization records for our files. Please
return a copy of your child’s immunization record from your physician within 30
days.
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