Kindergarten Registration Form

First Name

Last Name

Gender

Birth Date

Home Phone

Address

City

State

Country

Zipcode

Parent/Guardian Information

Name

Area

Phone Number

Work

E-mail

Address - Same As Child

Would your child like to be in a class with a friend

If yes, name and age of friend(s)

Is your child immunized

Does your child have any allergies

If yes please list, including any food or drug allergies

Does your child have any medical conditions

Does your child require any medication? If yes, please list these medications

Do you authorize us to administer the medications listed above

Please list the people authorized to pick up your child

Does your child have any siblings

If yes, what is their age

Comments

Signature

Signed Date