Preschool Registration Form - Ohio Department Of Education Page 2

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C
C
hild's History of Hospitalization:
hild's Disease History:
C
hild's Allergies/Treatment:
Child's Dietary Needs/Restrictions:
NOTE: A MEDICATION FORM MUST BE COMPLETED FOR EACH MEDICATION ADMINISTERED WHILE IN PROGRAM ATTENDANCE
Child's Medication/s:
Section V - Registration Authorizations
Annual Class Roster: Each year the program
prepares a roster for each group of children. This
I authorize the following to be listed on the parent roster:
Yes
No
My child's name
roster will not be furnished to any persons other
than parents of children enrolled in our program.
Yes
No
Family name
Yes
No
Cell
Home
Work
Phone numbers
Yes
No
Exempt from immunizations because of religious conviction:
Child immunization records attached:
Yes
No
Signature of Authorized
Date
Family Member/Guardian

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