Horseheads Presbyterian Nursery School

REGISTRATION FORM

Child’s Name __________________________________________________________________

                     Last                                                                   First

Name your child likes to be called most ________________________________________________

Date of Birth _______________________________             Gender (circle)          Male           Female  

Home Address ______________________________________________ Zip _________________

Does your child have any allergies? __________________________________________________

Are there any medical problems of which we should be aware?       _____ No        _____ Yes (please explain)

______________________________________________________________________________

Is child right-handed or left handed? ___________________________________________________

Has your child had a previous group or preschool experience? (when?)__________________________

How did you hear about us? ________________________________________________________

Child resides with (check one) ____ Both Father & Mother    ______ Mother Only    _____ Father Only

                                       ____ Legal Guardian (relationship to child) _________________________

Father’s Name _________________________________________________________________

Employer_________________________________________ Work # _______________________

Home # _______________________________ Cell# ___________________________________

Mother’s Name ________________________________________________________________

Employer_________________________________________ Work # _______________________

Home # _______________________________ Cell# ___________________________________

Step-Parent Name ______________________________________________________________

Brothers (names & ages) __________________________________________________________

Sisters (names & ages) ____________________________________________________________

IN THE EVENT YOUR CHILD BECOMES ILL OR IN CASE OF EMERGENCY,

IF A PARENT CAN NOT BE REACHED FIRST, WHOM WOULD YOU LIKE US TO CALL: Emergency Contact Name ____________________________________ Home # ___________________________________

Cell # ______________________ Relationship to child ___________________________________

Day Care Provider’s Name _______________________________________________________

Home # _______________________________ Cell# ___________________________________

Office Use Only:     Date  Form Received______________        Fee pd.________       Room #_________

4 year old program  _____                          3 year old program      2 days_______   3 days_________