Memory Lane Preschool Entrance and Travel Permission

Date:______________

I would like my child to be enrolled: MWF_______ TTH______ 5 days_________

Child: ________________________________ Birthdate:____________________

First name child will be called, learn to write and recognize______________

Home Address______________________________ Phone #:_______________

Email :_________________________

Mother’s Name: __________________ Father’s Name______________________

Employed By:____________________ Employed By:______________________

Cell Phone:__________________ Cell Phone:______________________

Business Phone:______________ Business Phone:__________________

Does Child live with both parents?______One Parent:____Other________

Any brothers?_______ages________ Sisters?__________ ages________

If Parent or guardian cannot be reached in an emergency contact:

Name:_______________________relationship:____________ phone#__________

Name:_______________________relationship:____________ phone#__________

Who do you authorize to pick up your child other than those listed above.

Names______________________________________________________________

Allergies or other serious problems:_____________________________

Are there problems that would restrict your child’s activities___________________

___________________________________________________________________

Has your child had all required immunizations?__________

Child’s Dr:____________________________ Phone #_______________

Child’s Dentist:_________________________ Phone #_______________

TRAVEL PERMISSION : I give my permission for my child______________

to travel on all field trips with the class.

MEDICAL RELEASE : I, the parent/guardian, ____________________________

give permission for emergency aid or treatment, as necessary, to render to

____________________ ___by any licensed physician or hospital emergency first aid treatment room in the event we can not be reached for consultation.

Signed________________________________

Has your child had previous preschool experience?

Please give any information concerning your child which will be helpful in their experiences in preschool. (Fears, play, eating, likes and dislikes)

What goals do you have for your child that you feel the Preschool can enrich?

(Use back of the form if necessary)