PK4 registration form

PK4 Registration form

Please fill out the registration form below, and submit your non-refundable deposit on the previous page for a spot in PK4.

Student's Name

First Name

Last Name

Student's Preferred Name

Student's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Date of Birth

YYYY

Student's Age

Student's Sex

Mother/Guardian's Name

First Name

Last Name

Mother/Guardian Address

If different from student

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother/Guardian Phone

(###)

###

####

Mother/Guardian occupation

Mother/Guardian Email

Father Name

First Name

Last Name

Father's Address

If different from above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Phone

(###)

###

####

Father's Occupation

Father's Email

Do you regularly attend church?

Yes

If so, where

Person Responsible for Tuition Payments

Who will usually pick up your student?

Please list the names (other than parents) to whom student may be released:

Separate with commas

Allergies

Please separate with commas

Student's t-shirt size

Emergency contact

other than mother or father

First Name

Last Name

Emergency Contact Phone

(###)

###

####

As the parent and/or guardian of the registration applicant, I authorize treatment under the direction of any licensed physician in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue comfort if delayed. This authority is granted only after an attempt has been made to reach me first by phone at the numbers listed above.

Check yes to confirm

Yes

Family Physician's Name and Phone Number

Hospital Preference

During the school year, we take pictures of our special events and outings. In order to include pictures of your child on our website, literature or year-end slide shows, we must have a signed release from the child’s parent or legal guardian. Your child’s name will NOT be used in conjunction with their photo. A completed form must be turned in for each child enrolled in the preschool.

Check yes to confirm

Yes

Please Type out full name as your digital signature on this document.

By filling out the above and placing your name here you are effectively signing and legally agreeing to all the above stated information

First Name

Last Name