Preschool Registration Form - Ohio Department Of Education

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Office of Early Learning and School Readiness
Preschool
Registration Form
Revised 3/14/2017
This form meets Ohio Administrative Code. Programs may use this form or build their own.
Section I - Student & Family Information
Child's Name
Date of Birth
Please select 1, 2 or 3 to set call order of phone number used to reach you:
Family/Guardian Name
Home Address
Cell Phone
Call Order
City
State
Zip
Home Phone
Call Order
Employer Name
Work Phone
Call Order
Employer Street Address
City
State
Zip
Please select 1, 2 or 3 to set call order of phone number used to reach you:
Alternate Family Information:
Family/Guardian Name
Cell Phone
Call Order
Family Street Address
Home Phone
Call Order
City
State
Zip
Work Phone
Call Order
Employer Name
Employer Street Address
City
State
Zip
Section II - Authorization for Emergencies
List 2 Emergency Contacts for use ONLY if the parents cannot be contacted:
Name
Name
Street Address
Street Address
City
State
Zip
City
State
Zip
Please select 1, 2 or 3 to set call order of phone number used to reach emergency contact:
Home
Call Order
Home
Call Order
Cell
Call Order
Cell
Call Order
Work
Call Order
Work
Call Order
List Medical Contacts, In Case Of Emergency:
Physician
Dentist
Street Address
Street Address
City
State
Zip
City
State
Zip
Phone
Phone
Section III - Child's Health Information
Child's Chronic Medical/Health Needs
Please complete both pages of form

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