Emergency/enrollment Form
ADVERTISEMENT
1
2EMERGENCY/ENROLLMENT FORM
Benbrook United Methodist Preschool
STUDENT INFORMATION
Last Name
First Name
Name Called
Date of Birth
Sex
Home Phone
Student’s Address (Street/City/State/Zip)
PARENT/GUARDIAN INFORMATION
Last Name
First Name
Home Phone
Cell Phone
Work Phone
Mother
Father
Address (Street/City/State/Zip)
Mother
Father
Mother
E-MAIL ADDRESS(ES)
Employer
Marital Status
Church Affiliation
Mother
Father
Mother
If divorced, custody of the child is held by
In case of accident or serious illness, I request that the school contact me. If the school cannot reach me, I authorize the school
to contact the physician below and follow his/her instructions. In a life threatening emergency, the school will call 911 and
emergency personnel will attend to the child.
Name of Physician
Address
Phone
List any problem that your child may have such as: vision, speech, hearing, allergies, ADHD, ADD, physical handicap,
asthma or any serious illness or injury.
Is student on medication?
Describe
My child may be released to the following persons in addition to the above parents/guardians
Name
Home Phone
Cell Phone
Work Phone
Signed (parent/guardian)
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business