Preschool Registration Form
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1
2Little Pilgrims Preschool
2016 – 2017 Registration Form
Class ____________________________
Child’s name
Sex
Birthdate
Last
First
Middle
M/F
Month/Day/Year
Home address
Phone
Street
City
Zipcode
Mother’s name
Occupation
Work phone
Address
(If different than above)
Father’s name
Occupation
Work phone
Address
(If different than above)
Names and ages of other children in the family
Has your child been in preschool before?
Where?
Health History of child (include allergies and medical restrictions)
Is there any emotional or character trait in your child that you would like us to know about?
List any or all persons authorized to pick up your child from preschool. Children will only be released to those
listed below. Identification may be requested.
Name
Phone
Name
Phone
Name
Phone
*****************************************************************************************
Permission to Participate in Field Trips
(child’s name)
has my permission to participate in planned
preschool field trips. I understand that a parent or guardian must attend all off site field trips. If I cannot attend
I will designate an adult the responsibility of transporting my child. I understand that Little Pilgrims Preschool
employees will not be responsible for transporting my child. I hereby release Pilgrim Lutheran Church and its
preschool from any liability.
Signed
Date
Parent or guardian
Please attach a current copy of your student’s
immunization record and the $100 Registration fee
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