For office use:  M, W, F  a.m.                                                                                 Registration Fee Paid:   YES        NO

                               M, W, F  p.m.

                                T, Th  a.m.

Noah’s Park Christian Preschool

Registration Form

Child’s Name: _______________________________________________

Mother’s Name: _____________________________________________

Father’s Name: ______________________________________________

Child’s DOB: ____________________  Child’s SSN: _________________

Address: ____________________________________________________

Phone Number: _____________________________________________

Mother’s Place of Work and Number: ___________________________

Father’s Place of Work and Number: ____________________________

Who to contact in case of emergency: (name and phone number)

____________________________________________________________

Child’s Doctor: _______________________________________________

Do we have permission to take your child to Avera St. Luke’s in case of emergency?   Yes    No

Is your child potty trained?   Yes   No  (child must be potty trained)

Who is allowed to pick up your child?  (list all people and phone #s)

1. __________________________________________________________

2. __________________________________________________________

3. __________________________________________________________

4. __________________________________________________________

Does your child have any allergies?  Yes  No

If yes, what are they? ___________________________________________

Are you willing to provide snacks on rotation?  Yes  No

Any other information you would like us to have about your child: