Registration Form

 
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Preliminary Registration Application


Childs Name *
Childs Name
Child's Street Address *
Child's Street Address
Place of Primary Residence
Child's Date of Birth *
Child's Date of Birth
Primary Parent Contact Info
Primary Parent Contact *
Primary Parent Contact
Primary Parent Address *
Primary Parent Address
Primary Parent (Primary Phone) *
Primary Parent (Primary Phone)
Primary Parent (Secondary Phone)
Primary Parent (Secondary Phone)
Primary Parent (Work Phone) *
Primary Parent (Work Phone)
Secondary Parent Contact Info
Please Fill out even if the same as Primary Parent
Secondary Parent Name *
Secondary Parent Name
Secondary Parent Address *
Secondary Parent Address
Secondary Parent (Primary Phone) *
Secondary Parent (Primary Phone)
Secondary Parent (Secondary Phone) *
Secondary Parent (Secondary Phone)
Secondary Parent (Work Phone) *
Secondary Parent (Work Phone)
Pickup Permissions
Those not allowed to pickup your child from playschool
Is there someone that is not allowed to pick up your child? *
If Yes, Please provide their Full Name
If Yes, Please provide their Full Name
Emergency Contact (OTHER THAN PARENT)
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Emergency Contact Address *
Emergency Contact Address
Family Physician Info
Family Physician Name *
Family Physician Name
Family Physician Phone
Family Physician Phone
Family Physician Work Address *
Family Physician Work Address
Health/Developmental Info
Does your child require medication that must be given daily? *
Are your child's immunizations up-to-date? *
I consent to the administration of health care by the staff of the Westend Community Playschool. Ifemergency assistance is required, I understand the medical professionals will decide where medicalassistance will be sought. I acknowledge that I will be responsible for the cost of ambulance services, ifany *