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

Child Address

Address Line 1

Address Line 2

City

State

Zip Code

Child Phone

Mother's Information

Mother's Name

First

Last

Mother's Phone

Mother's Address (If different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Mother's Email

Mother's Employer

Mother's Work Phone

Mother's Hours

Father's Information

Father's Name

First

Last

Father's Phone

Father's Employer

Father's Work Phone

Father's Hours

Church Membership

Mother

Father

Church Name

Does Your Child Attend Bible Class?

Yes
No

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

Name 1

First

Last

Phone 1

Name 2

First

Last

Phone 2

Name 3

First

Last

Phone 3

Emergency Information

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

First

Last

Emergency Phone

Emergency Address

Address Line 1

Address Line 2

City

State

Zip Code

Physician Information

Physician Name

First

Last

Physician Phone

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Hospital Preference

Hospital 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

child Please you

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 feel would be helpful for the teacher

How did you learn of our program?

Permission Agreement

I do hereby authorize emergency medical care for...

Signature of parent or guardian

Clear Signature

Date