Preschool Wed Night Registration
For children who are at least 4 yrs old by 7-31-18 and not yet in Kdg
Child Information
Child's First Name *
Your answer
Child's Last Name *
Your answer
Date of Birth (must be 4 by 7-31-18) *
MM
/
DD
/
YYYY
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Parent/Guardian Information
Parent/Guardian First Name(s) *
Your answer
Parent/Guardian Last Name *
Your answer
Parent/Guardian Email *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
Emergency Contact Info (other than parent/guardian)
Emergency Contact Name *
Your answer
Relationship to Child *
Your answer
Emergency Contact Phone Number *
Your answer
Miscellaneous Information
Allergies, medical conditions or anything else you would like us to be aware of:
Your answer
*
Required
*
Required
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