FUMP Registration 2021-2022
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Name of child:
Birth Date: ___/___/____
MM
/
DD
/
YYYY
Sex: M __ F___
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Address:
City, State, Zip Code:
Child lives with: ___both parents ____Only Mother ____Only Father _____Other (Explain)
Full Name of Mother/Guardian:____________________________
Mothers Address if different from Childs:
Home Phone:
Cell Phone:
Email:
Work Phone:
Place of Work:
Full Name of Father/Gaurdian:
Father's address if different from child:
Home Phone
Cell Phone:
Email:
Work Phone:
Place of Work:
Person's to contact in case of Emergency/authorized to pick up Child:
Name of Childs Doctor:
I authorize that the above person(s) may be contacted in case of emergency: (By checking this box acknowledges my signature for the above question.)
Signature of Parent/Gaurdian: (Please Type)
I Would like to Enroll my child in the following class:
I agree to pay FUMP $100 Registration Fee. These can be dropped off at the Preschool office or mailed to PO Box 696, Pilot Mountain NC, 27041
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