Noah's Ark Preschool Registration T/Th 3/4s

Child's Information

Child's Name

Nickname

Address

Birthdate

Gender

Male Female

Allergies

Gluten Dairy Peanuts Tree Nuts Eggs Latex None

Additional Allergy Information

Medical Concerns

Doctor/Clinic Name

Doctor/Clinic Phone Number

Dentist's Name

Dentist's Phone Number

Family Information

Parent 1 Name

This address will receive a confirmation email

Mobile Phone

Home Phone

Work Phone

Parent 2 Name

Parent 2 Email

Parent 2 Mobile Phone

Sibling Names and Birthdates

Church Affiliation

How did you hear about Noah's Ark Preschool?

Emergency Contact and Alternate Pickup

Emergency Contact Name

Emergency Contact FULL ADDRESS

Emergency Contact Phone

Emergency Contact Relationship

Emergency Contact 2 Name

Emergency Contact 2 FULL ADDRESS

Emergency Contact 2 Phone

Emergency Contact 2 Relationship

Alternate Pickup Name

Alternate Pickup Phone

Alternate Pickup Name 2

Alternate Pickup Phone 2

I give permission to Noah's Ark Preschool to make whatever emergency measures as judged necessary for the care and protection of my child while under their supervision.

In case of medical emergency, I understand that my child will be transported to an appropriate facility by the local emergency unity for treatment if the local emergency resource deems it necessary.

It is understood that in some medical situations, the staff will need to contact that local emergency resource before the parent, child's physician and/or other adult acting on the parent's behalf.

Signature

A registration fee of $50 (+processing fee) is required to hold a seat in the class.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Noah's Ark Preschool Registration T/Th 3/4s - Fall 2023

Description

Noah's Ark Preschool Registration T/Th 3/4s - Fall 2023

Description

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