Preschool Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4 Allergy of aware. Child InformationFull name of child *FirstLastWhat does the child like to be called?Birth Date *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneMother's InformationName *FirstLastPhone *Address (If different from above)Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *EmployerWork PhoneHoursFather's InformationName *FirstLastPhone *EmployerWork PhoneHoursNextChurch MembershipMotherFatherChurch Name *Does Your Child Attend Bible Class? *YesNoPick-Up Authorization Please list adults (other than parents) authorized to pick up your child Name *FirstLastPhone * Add Remove NextEmergency InformationName of person to contact in an emergency if parent cannot be located *FirstLastPhone *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhysician InformationNameFirstLastPhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHospital PreferencePhoneMedical HistoryAllergiesPlease include food, drugs, external factors, or any other typesHow 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 SkillsDoes your child need help with his/her clothes in the restroom? *YesNoPlease describe any special routine necessary for nap time.Special blanket, toy, pacifier, etcWhat 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? *AllWhat they wantPlease give any further information that you fel would be helpful for the teacherHow did you learn of our program?NextPermission AgreementI do hereby authorize emergency medical care for... *Signature of parent or guardian * Clear Signature Date *Submit