Preschool Registration Form
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1REGISTRATION FORM
2016-2017
2401 Woodbourne Ave. * Louisville,Ky 40205 * (502) 451-3434
Child’s Name__________________________________________ Birthday_________________
Date_________________
Name Child Goes By________________________________________Male_____Female_____
Please place an X next to
your choice of program or
Parent(Mr./Dr./Ms.)__________________________ Parent(Mr./Dr./Ms.)______________________
CIRCLE CHOICE OF
DAYS IF APPLICABLE
Address________________________________
Address______________________________
Infant-2 day
M T W TH F
Zip________ Phone______________________
Zip ________ Phone____________________
Infant-3 day
M T W TH F
E-mail _________________________________
E-mail______________________________
Infant-5 day
Toddler-2 day M T W TH F
Occupation_____________________________
Occupation____________________________
Toddler-3 day M T W TH F
Business Phone________________________
Business Phone________________________
Toddler-5 day
Previous School Experience Yes ___ No ___ If yes, where ______________________________
2 yr-2 day
M T W TH F
Child’s General Health_____________________________________________________________
2 yr-3 day
M T W TH F
Any Fears Yes___ No ___ If yes, what______________________________________________
2 yr-5 day
Food Allergies _________________________________________________In order for your child
to be included on our “Food Allergy List” we must have a Food Allergy Action Plan form completed
3 yr-5 day
by the doctor. Please contact the office for this form.
4 yr-5 day
Any emotional, physical, learning disabilities or other circumstances we should be aware of
_______________________________________________________________________________________________________
Physician___________________________________________Phone________________________________________________
Please indicate if you are a member of Congregation Adath Jeshurun Yes_____ No_____
Are you of the Jewish faith Yes_____ No_____
Please indicate if you are a member of another Congregation_______________________________________________________
I/we understand that the enrollment of (child/children’s name)_______________________________________________________
Is made for the full school year and that as Parents or Guardians we are fully liable for the tuition for the full academic year and all
other expenses incurred by the student and no portion of any fees already paid will be refunded. Students are enrolled for the full
academic year and no adjustment of charges will be made for absence, withdrawal or dismissal.
This application is valid only when accompanied with the registration fee which is non- refundable.
Licensed by the Department of Human Resources
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