Tuesday/Thursday School Application - LaVergne Church of Christ

Child Information

Full name of child

First

Last

What does the child like to be called?

Birth Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Mother's Information

Name

First

Last

Phone

Address (If different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Email

Employer

Work Phone

Hours

Father's Information

Name

First

Last

Phone

Employer

Work Phone

Hours

Church Membership

Mother

Father

Church Name

Does Your Child Attend Bible Class?

Yes
No

Pick-Up Authorization

Please list adults (other than parents) authorized to pick up your child

Name

First

Last

Phone

Emergency Information

Name of person to contact in an emergency if parent cannot be located

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Physician Information

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Hospital Preference

Phone

Medical History

Allergies

Please include food, drugs, external factors, or any other types

How Does Allergy Manifest Itself?

Please explain any physical or emotional factors/conditions of which the teacher should be aware.

Is there any reason your child should not participate in normal physical activities?

Please explain and provide a doctor's statement.

Social/Behavior Skills

Does your child need help with his/her clothes in the restroom?

Yes
No

Please describe any special routine necessary for nap time.

Special blanket, toy, pacifier, etc

What methods do you use in guiding your child's behavior?

Do you want your child to eat all their lunch or only what they want?

All
What they want

Please give any further information that you fel would be helpful for the teacher

How did you learn of our program?

Permission Agreement

I do hereby authorize emergency medical care for...

Address which in

Signature of parent or guardian

Clear Signature

Date