2019-20 Herriman High Preschool Registration Wait List, 4 yr old, T/Th
Please verify that your child is currently 4 years old or will be 4 as of September 1 2019 and would like the Tuesday/Thursday option. *
Contact Information
Child's First Name (As Shown On Birth Certificate) *
Your answer
Child's Preferred Name (Nick Name) *
Your answer
Child's last Name *
Your answer
Child's Middle Name *
Your answer
Child's Date of Birth *
mm/dd/yyyy
Your answer
Ethnicity *
Your answer
Gender *
Your answer
Child's Preferred Language *
Your answer
Child's Home Address *
as you would address an envelope
Your answer
Parent's Home Number *
Your answer
Parent's Preferred Email Address *
Your answer
Mother's First Name
Your answer
Mother's Last Name
Your answer
Mother's Cell Number
Your answer
Mother's Work Number
Your answer
Father's First Name
Your answer
Father's Last Name
Your answer
Father's Cell Number
Your answer
Father's Work Number
Your answer
In case of a custodial issue, please inform the Preschool Director and make a note on this record:
Your answer
1) Emergency Contact First and Last Name *
Your answer
1) Relation to child *
Your answer
1) Emergency Contact Phone Number *
Your answer
2) Emergency Contact First and Last Name *
Your answer
2) Relation to child *
Your answer
2) Emergency Contact Phone Number *
Your answer
Child's Physician Name *
Your answer
Physician's Phone Number *
Your answer
Physician's Address *
Your answer
Hospital Preference *
Your answer
Health & Personal Information
Does your child have any physical problems of which we should be aware of? *
If yes, please explain.
Your answer
Does your child take any prescription medication on a regular basis? *
If yes, please list.
Your answer
Does your child have any allergies? *
If yes, please explain.
Your answer
Are there any special family circumstances which may be a factor in your child's present behavior - divorce, death, new baby, recent move, hospitalization, etc.? *
If yes, please explain.
Your answer
Do you have any concerns about your child's present behavior? *
If yes, please explain.
Your answer
Department Permission Form
I hereby give permission for my child to leave the Herriman High School Preschool only with the person(s) named below. Picture identification will be required. My child will not be allowed to leave the premises with any person(s) not on this list. It is my responsibility to notify the center, in writing, of any changes.
1) First and Last Name *
Your answer
1) Relation to child *
Your answer
In situation where there is a custodial issue, we must have legal documentation to show guardianship. We need this to prevent an unathorized person from visiting or picking up a child. If there is a speration or divorce custody problem, of which we should be made aware please explain below:
Your answer
Name of person(s) who MAY NOT pick up child.
Your answer
I understand that in addition to this registration form, I must also sign the Parent Consent Agreement before my child may attend Herriman High Preschool Lab. *
I understand that in addition to this registration form, I must also submit current immunization records or personal exemption form before my child may attend Herriman High Preschool Lab. *
I understand that in addition to this registration form, I must provide a copy of an official birth certificate before my child may attend Herriman High Preschool Lab. *
I understand that in addition to this registration form, I must pay the $40 registration fee to the Herriman High School Office to hold my childs spot in the Mini Mustang Preschool. *
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