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Pre-School Registration Form (Part 2)
Thank you for your interest in the Grand Ledge Public Schools Preschool Program. Please take a moment to provide us with the additional information below to complete your student's registration.
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STUDENT INFORMATION
Full, Legal Name (for verification purposes)
First
*
Your answer
Middle Initial
Your answer
Last
*
Your answer
Date of Birth
*
mm/dd/yyyy
MM
/
DD
/
YYYY
PROGRAM OPTION INFORMATION
If you chose to participate in the 3- or 4-year old all day program, please provide us with the following information.
Which days will your student be attending?
Check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
What time will you drop your child off?
Time
:
AM
PM
What time will you pick up your child?
(estimate)
Time
:
AM
PM
PARENT INFORMATION
Father's Full Name
Your answer
Father's Address (street, city, zip)
{If different from student}
Your answer
Father's Home Phone
Your answer
Father's Work Phone
Your answer
Father's Cell Phone
Your answer
Father's eMail Address
Your answer
Mother's Full Name
Your answer
Mother's Address (street, city, zip)
{If different from student}
Your answer
Mother's Home Phone
Your answer
Mother's Work Phone
Your answer
Mother's Cell Phone
Your answer
Mother's eMail Address
Your answer
EMERGENCY CONTACT INFORMATION
Please provide us with the following information in the event of an emergency and parent(s) cannot be reached.
Name of Secondary Contact Person
Full Name
Your answer
Relationship to Child
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Name of Secondary Contact Person
Full Name
Your answer
Relationship to Child
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Persons Authorized to Pick Up Your Student
Limit 3
Your answer
Persons NOT Authorized to Visit or Pick Up Your Student
(Appropriate legal paperwork must be attached is a parent is not allowed to visit/pick up student.)
Your answer
List any Special Accommodations your Child Needs to Participate in the Program
Your answer
Share any additional information you would like your child's teacher to be aware of.
Your answer
MEDICAL INFORMATION
Name of Physician or Clinic
Your answer
Address
(street, city, zip)
Your answer
Telephone Number
Your answer
Please specify any allergies, medical conditions, modified diets or medications
Your answer
Electronic Signature
By typing my name below, I warrant the truthfulness of the information provided in this application.
Full Name
*
(First, Last)
Your answer
*
I understand checking this box constitutes a legal signature confirming that I acknowledge and agree to the submission of this Registration Form.
Required
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