3-Year-Old Preschool Registration Form Page 2
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2____________________________________________________________________________________________________________
Medical Information
Family Doctor ________________________________________ City ___________________ Phone # ________________________
Does this child have any allergies (for example: food, medications, insects)? Yes No
If yes, please specify ___________________________________________________________________________________
Does this child have any ongoing illnesses or medical conditions other than allergies listed above? Yes No
If yes, please specify ___________________________________________________________________________________
Does this child have any speech, vision, hearing or learning difficulties the school should know about? Yes No
If yes, please specify ___________________________________________________________________________________
Family Dentist ________________________________________ City ___________________ Phone # ________________________
Family Eye Doctor _____________________________________ City ___________________ Phone # ________________________
__________________________________________________________________________________________
Emergency Contacts
(Please list only those contacts who would be able to pick up this child in case of sickness or other emergency) Do
not include parent contacts listed on the front of this form. An attempt will always be made to contact a parent first.
_________________________________
____________________________
________________________
Name
Phone
Relationship
__________________________________
____________________________
________________________
Name
Phone
Relationship
__________________________________
____________________________
________________________
Name
Phone
Relationship
___________________________________________________________________________________________________________
Siblings
(Please list only those siblings who are currently attending Maquoketa Community Schools)
__________________________________
_______ ___________
_________
_________________________
Name
Birth date
Gender
School Currently Attending
__________________________________
_______ ___________
_________
_________________________
Name
Birth date
Gender
School Currently Attending
__________________________________
_______ ___________
_________
_________________________
Name
Birth date
Gender
School Currently Attending
____________________________________________________________________________________________________________
PICTURE RELEASE: I hereby do___/do not___ give consent to have my child photographed or videotaped for use by the district
and preschool centers in newspapers, publicity, advertisement, or for educational purposes. ________
(intial)
Restrictions:
TRAVEL AND ACTIVITY AUTHORIZATION: I hereby do___/do not___ give permission for my child to leave the above
named facility for field trips to special places; and to travel by car, public transportation, or by walking. I understand that I will be
notified in advance of each activity. ________
(intial)
Restrictions:
____________________________________________________________________________________________________________
Please return the following information to: Jan Wagner, District Registrar, 1003 Pershing Road, Maquoketa, IA 52060.
If you have questions, please call Jan at 563-652-5157.
☐Registration Form ☐Physical Form ☐Birth Certificate ☐Immunization Records ☐$30 Book Fee
(if qualified, request book fee waiver form)
1/27/16
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