CROSSROADS COMMUNITY PRESCHOOL AN EARLY CHILDHOOD ...
CROSSROADS COMMUNITY PRESCHOOL AN EARLY CHILDHOOD EDUCATIONAL CENTER REGISTRATION FORM NAME of CHILD_______________ _________________ _________________ (Please Print) (last) (first) (middle) DATE OF BIRTH___________ __________ ______________ SEX: M/F (month) (day) (year) (circle) NAME OF FATHER_______________OF MOTHER____________________ (or guardian) ADDRESS OF CHILD______________________________________________ _________________________________________________________________ HOME TELEPHONE_______________________ CELL PHONE_____________________________EMAIL_________________ PERSON TO CONTACT IN CASE OF EMERGENCY__________________ (other than yourself) THEIR TELEPHONE NUMBER__________________ IS ENGLISH YOUR CHILD’S FIRST LANGUAGE?____YES____NO If you answer no, what is your child’s first language?____________________ YEAR OF NURSERY SCHOOL ENTRY: SEPTEMBER _______ 3 YR. OLD PROGRAM______9:00-11:30 TUES. & THURS. (2 DAYS) 4 YR. OLD PROGRAM______9:00-11:30 MON.*WED.*FRI.(3 DAYS) 4 YR. OLD PROGRAM______12:30-3:00 MON. THRU FRI. (5 DAYS) 4 YR. OLD PROGRAM______12:30-3:00 MON.*WED.*FRI.(3 DAYS CHILDREN IN THE 3 YR. OLD PROGRAM MUST BE TOILET TRAINED AND HAVE HAD THEIR 3RD BIRTHDAY BY AUG. 31 [over please]
CHILD’S IMMUNIZATION RECORDS: PLEASE ATTACH A COPY OF THE DOCTOR’S IMMUNIZATION RECORDS TO VERIFY THAT YOUR CHILD HAS HAD THE FOLLOWING IMMUNIZATIONS: POLIO * MEASLES * MUMPS * RUBELLA * HIB VACCINE DIPHTHERIA * TETANUS * PERTUSSIS * VARICELLA * HEP B DOES YOUR CHILD HAVE ANY ALLERGIES? _____YES_____NO IF YES PLEASE LIST ALLERGIES ____________________________ _____________________________________________________________ PLEASE INDICATE ANY ASPECTS OF YOUR CHILD’S HEALTH AND DEVELOPMENT THAT WE SHOULD BE AWARE OF IN ORDER FOR US TO DO THE BEST JOB WE CAN. EXAMPLE: SEIZURES * ASTHMA * HEARING, VISION OR SPEECH DIFFICULTIES. FOOD RESTRICTIONS - FOODS YOUR CHILD CANNOT EAT.
IS YOUR CHILD ON ANY MEDICATION? ______YES______NO IF YES WHAT MEDICATION IS YOUR CHILD ON?_________________ HAS YOUR CHILD HAD ANY OPERATIONS? _____YES_____NO IF YES PLEASE LIST OPERATIONS________________________________ SIGNATURE OF PARENT OR GUARDIAN__________________________ DATE OF APPLICATION__________________ NON-REFUNDABLE REGISTRATION FEE: $40.00 CROSSROADS COMMUNITY PRESCHOOL 104 HEATHER ROAD MAILING ADDRESS: 6700 MONTGOMERY AVE. UPPER DARBY, PA 19082 (610) 352-4092 E-mail: [email protected]
CROSSROADS COMMUNITY PRESCHOOL AN EARLY CHILDHOOD EDUCATIONAL CENTER PICK UP TIME It is important that we establish regular pick up people for your child. This is so important! We do this not to inconvenience you, but for the safety of your child. You can have up to four (4) people that are authorized to pick up your child (including mother & father) on this list. Your child’s teacher will only allow these people to pick up your child. Please include, on this list, your emergency contact from the registration form. Thank you for your cooperation. ________________________________ Your child’s name [Please Print] NAMES OF PICK UP PEOPLE [Please Print]
RELATIONSHIP TO YOUR CHILD [Please Print]
______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ___________________________________ Authorized Parent or Guardian’s Signature School year: 2017-2018
CHILD’S IMMUNIZATION RECORDS: PLEASE ATTACH A COPY OF THE DOCTOR’S IMMUNIZATION RECORDS TO VERIFY THAT YOUR CHILD HAS HAD THE FOLLOWING IMMUNIZATIONS: POLIO * MEASLES * MUMPS * RUBELLA * HIB VACCINE DIPHTHERIA * TETANUS * PERTUSSIS * VARICELLA * HEP B DOES YOUR CHILD HAVE ANY ALLERGIES? _____YES_____NO IF YES PLEASE LIST ALLERGIES ____________________________ _____________________________________________________________ PLEASE INDICATE ANY ASPECTS OF YOUR CHILD’S HEALTH AND DEVELOPMENT THAT WE SHOULD BE AWARE OF IN ORDER FOR US TO DO THE BEST JOB WE CAN. EXAMPLE: SEIZURES * ASTHMA * HEARING, VISION OR SPEECH DIFFICULTIES. FOOD RESTRICTIONS - FOODS YOUR CHILD CANNOT EAT.
IS YOUR CHILD ON ANY MEDICATION? ______YES______NO IF YES WHAT MEDICATION IS YOUR CHILD ON?_________________ HAS YOUR CHILD HAD ANY OPERATIONS? _____YES_____NO IF YES PLEASE LIST OPERATIONS________________________________ SIGNATURE OF PARENT OR GUARDIAN__________________________ DATE OF APPLICATION__________________ NON-REFUNDABLE REGISTRATION FEE: $40.00 CROSSROADS COMMUNITY PRESCHOOL 104 HEATHER ROAD MAILING ADDRESS: 6700 MONTGOMERY AVE. UPPER DARBY, PA 19082 (610) 352-4092 E-mail: [email protected]
CROSSROADS COMMUNITY PRESCHOOL AN EARLY CHILDHOOD EDUCATIONAL CENTER PICK UP TIME It is important that we establish regular pick up people for your child. This is so important! We do this not to inconvenience you, but for the safety of your child. You can have up to four (4) people that are authorized to pick up your child (including mother & father) on this list. Your child’s teacher will only allow these people to pick up your child. Please include, on this list, your emergency contact from the registration form. Thank you for your cooperation. ________________________________ Your child’s name [Please Print] NAMES OF PICK UP PEOPLE [Please Print]
RELATIONSHIP TO YOUR CHILD [Please Print]
______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ___________________________________ Authorized Parent or Guardian’s Signature School year: 2017-2018
