UPWARD BOUND CHRISTIAN PRESCHOOL REGISTRATION 2009/2010
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CHILD'S NAME________________________________________________________________________________
BIRTHDATE___________________________________TELEPHONE_____________________________________
ADDRESS_____________________________________________________________________________________

FATHER'S NAME______________________________________________________________________________
ADDRESS_____________________________________________________________________________________
PLACE OF EMPLOYMENT______________________________________________________________________
HOME PHONE_____________________ WORK PHONE__________________CELL PHONE________________

MOTHER'S NAME_____________________________________________________________________________
ADDRESS_____________________________________________________________________________________
PLACE OF EMPLOYMENT______________________________________________________________________
HOME PHONE_____________________ WORK PHONE__________________CELL PHONE________________

PEOPLE AUTHORIZED TO TAKE CHILD OUT OF PRESCHOOL:
NAME_______________________________________________RELATIONSHIP___________________________
HOME PHONE__________________________________CELL PHONE___________________________________
NAME_______________________________________________RELATIONSHIP___________________________
HOME PHONE__________________________________CELL PHONE___________________________________

HEALTH INFORMATION:
ALLERGIES:___________________________________________________________________________________
______________________________________________________________________________________________
FOODS TO AVOID:_____________________________________________________________________________
PHYSICAL LIMITATIONS:_______________________________________________________________________

OTHER PROBLEMS/CONCERNS TEACHER SHOULD BE AWARE OF:__________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

DOCTOR'S NAME_____________________________________________ PHONE__________________________
DENTIST'S NAME_____________________________________________ PHONE__________________________

PLEASE ATTACH A COPY OF YOUR CHILD'S IMMUNIZATION RECORDS.
     
 

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