home
newsletter calendar guestbook
about usphilosophyregistrationphotoscontactsponsors

Online Registration Form

 

Please fill out the registration form below. Once you click the submit button at the bottom of this page, the completed form including the Medical Release and Policy Acknowledgements will be emailed to the email address you provide here.

 

Your Name:

Email Address:

 

Registration Form

 

Student Information
Student’s Name:
Birthday:
Sex:
 Male     Female M-D-YYYY or M/D/YYYY
Registering For:
 2 Days     3 Days     5 Days
Summer     Fall     Both
Requested Days :
 Mon    Tue    Wed    Thu    Fri

 

Address
Address:
City:
State:
Zip:
Home Phone:

Mother's Contact Information
Name:
Work Phone:
Cell Phone:

Father's Contact Information
Name:
Work Phone:
Cell Phone:

Emergency Contact Information
Emergency Contact :
Phone:

Child Pickup Authorization  
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:

Medical Information  
Physicians Name:
Phone:
Preferred Hospital:
Insurance Company:
Policy #:
Medical Conditions/Allergies:

Other Information

 
Home  ::  Newsletter  ::   Calendar  ::   Guestbook  ::   About  ::   Philosophy  ::   Regristration Form  ::   Photos  ::   Contact  ::   Sponsors
 
© 2009 Elite Preschool