Preschool Registration

Child's full name *

Name child goes by

Birthdate *

Age on September 1, 2012 *

3

4

5

Sex *

Male

Female

Child's home address *

Child's home phone number *

Child's father's name *

Father's home address *

Father's phone number *

Father's employer, occupation & work address

Father's email address *

Child's mother's name *

Mother's home address *

Mother's phone number *

Mother's employer, occupation & work address

Mother's email address *

Does the child have any brothers/sisters? *

Yes

No

List brothers/sisters name, age, grade and if they live with the child.

List any other persons living with the child and their relationship to the child.

Is the child right or left handed? *

Right

Left

Unsure

Has the child had a previous group or preschool experience? *

Yes

No

Previous group or preschool experience

Does the child have any allergies or are there any medical problems or concerns of which we should be aware? Is the child on any type of medication? *

Are there any special food or eating instructions? *

Any additional information concerning discipline, child's communication, comforting, etc. *

Three Year Old Classes - FIRST preference

Three Year Old Classes - SECOND preference

Four Year Old Classes - FIRST preference

Four Year Old Classes - SECOND preference

Are you registering for Transitional Kindergarten?

Are you interested in full-time/part-time childcare before or after preschool hours? *

Yes

No

Maybe

Have you had a child previously attend Four Mile Preschool? (if so, list name)

Church affiliation

What school district will your child be attending? *

Would you like to be on Four Mile Church's mailing list for activities, services and programs?

Yes

No