Pre-K Registration Form:

School Location

Please select the school you would like to enroll into:
Choose OneMidtownEagle's Landing

Child Information

Child's Last Name

Child's First Name

Child's Middle Name

Child's Name Suffix: (i.e. Jr, Sr, II,III)

Child's Social Security Number

Child's Date of Birth (MM/DD/YYYY)

Sex
MaleFemale
Home Street Address

County

City

Zip Code

Phone Number (i.e. 555 555 5555)

If the Student is transferring from another Pre-K, please provide the following:
Previous School Name

Last Date in Attendance ( MM/DD/YYYY )

Parent Guardian Information

Parent/Guardian #1 Information

Parent #1 Last Name

Parent #1 First Name

Parent 1 Middle Initial

Please note - you only need to enter the address if it is different from the child
Home Street Address for Parent #1

City for Parent #1

State for Parent #1

Zip Code for Parent #1

Phone Number for Parent #1

Cell Phone Number for Parent #1

Email Address for Parent #`1

Place of Employment for Parent #1

Work Phone Number for Parent #1

Work Address for Parent #1

Work City for Parent #1

Work State for Parent #1

Work Zip Code for Parent #1

Parent/Guardian #2 Information

Parent/Guardian#2 Last Name

Parent/Guardian#2 First Name

Parent/Guardian #2 Middle Initial

Parent/Guardian #2 Phone Number

Parent/Guardian #2 Cell Phone Number

Parent/Guardian #2 Email Address

Home Address If different from child

Parent/Guardian #2 City

Parent/Guardian #2 State

Parent/Guardian #2 Zip Code

Parent/Guardian #2 Place of Employment

Parent/Guardian #2 Work Phone Number

Parent/Guardian #2 Work Address

Parent/Guardian #2 Work City

Parent/Guardian #2 Work State

Parent/Guardian #2 Work Zip

Emergency Contact Information

Emergency Contact #1

Emergency Contact #1 Name and Relationship

Emergency Contact Cell Phone Number

Emergency Contact Alternate Phone Number

Emergency Contact Email Address

Emergency Contact #2

Emergency Contact #2 Name and Relationship

Emergency Contact #2 Cell Phone Number

Emergency Contact #2 Alternate Phone Number

Emergency Contact #2 Email

Date You Plan to Sign This Document ( MM/DD/YYYY) Note - enter today if you are unsure

Child Maintenance Information:

Child's Living Arrangements:
BOTH PARENTSFATHERMOTHEROTHER

Child's Legal Guardian
BOTH PARENTSFATHERMOTHEROTHER

The child may be released to the person(s) signing this agreement or to the following people:

Person #1 your child can be released to

Name and Address of Person #1:

Relationship and Cell Phone Number of Person #1

Person #2 your child can be released to

Name and Address of Person #2:

Relationship and Cell Phone Number of Person #2

Person #3 your child can be released to

Name and Address of Person #3:

Relationship and Cell Phone Number of Person #3

Person #4 your child can be released to

Name and Address of Person #4:

Relationship and Cell Phone Number of Person #4

Health Information:

Child's Physician or Clinic's Name (Child's Primary Health Source)
Date of Last Full Health Screening

Clinic's Number

My child has the following special needs:

Enter any additional needs below

Enter any additional needs below

The following special accomodation(s) may be required to most effectively meet my child's needs while at this center:

Enter any additional accomodations below:

Enter any additional accomodations below:

If your child is currently on medication(s) prescribed for long-term continuous and/or has any pre-existing allergies, illness, or health concerns: please enter them below.

Enter any additional medications , allergies, conditions, illnesses or health concerns below

Enter any additional medications , allergies, conditions, illnesses or health concerns below