Preschool Re-Enrollment Form
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1Registration Fee Paid $_________
Date Paid ___________________
Class_________________
Method of Payment:
Preschool Re-Enrollment Form
Teacher_______________
_____Check
Entered_______________
_____Cash
Blue Medical Form Received:_____
*If you are enrolling a student for the very first time at Northridge Preschool, you must
complete the long application form. Only current Preschool students may use this
re-enrollment application.
Student Information:
Full Name: ___________________________________________________________________________________
Address: _____________________________________________________________________________________
City, State, Zip Code: ___________________________________________________________________________
Phone Number: ________________________________________________________________________________
Date of Birth: __________________________________
Gender: ______________________________________
List any medical concerns that we should be made aware of in case of emergency; such as daily medications, allergies
to foods or medications, etc.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please check the program you are interested in for your child:
4 Year Olds: _____ 3 Days (M, W, F)
_____ 5 Days (M-F) _____ TK*
(*All Transitional Kindergarten interests MUST fill out the form on the reverse side of this application.)
Family Information:
Father’s full name: ___________________________
Mother’s full name: ___________________________
Address: (only if different from student)
Address: (only if different from student)
___________________________________________
____________________________________________
Home Phone: (only if different)
Home Phone: (only if different)
___________________________________________
____________________________________________
Place of Employment: _________________________
Place of Employment: __________________________
Work Phone: ________________________________
Work Phone: _________________________________
Cell Phone: _________________________________
Cell Phone: __________________________________
E-Mail address: ______________________________
E-Mail address: _______________________________
Emergency Contacts:
If parents cannot be contacted, indicate responsible adults to contact in case of emergency. These persons also have
permission to pick up your child from school, in the event you are unable to do so.
Contact 1: Name: _________________________________ Relationship: _________________________________
Home Phone: __________________ Work Phone: ____________ Cell Phone: _____________________________
Contact 2: Name: _________________________________ Relationship: _________________________________
Home Phone: __________________ Work Phone: ____________ Cell Phone: _____________________________
Church Information:
Church affiliation (if any): ______________________________________________________________________
Do you and your family attend regularly?
Yes
or
No
A non-refundable registration fee of $75.00 must accompany this application to
guarantee student placement.
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