Clemmons Moravian Preschool 2018-19 School Year Registration Form
PLEASE CHECK PROGRAM DESIRED. Please read the options carefully.
Child's Name *
Your answer
Prefers to be called
Your answer
Date of Birth *
Your answer
Home phone *
Your answer
Home Street Address *
Your answer
City, State and Zip *
Your answer
Mother's Name *
Your answer
Mother's Cell Phone
Your answer
Mother's Work Phone
Your answer
Mother's Email Address
Your answer
Mother's Occupation
Your answer
Father's Name *
Your answer
Father's Cell Phone
Your answer
Father's Work Phone
Your answer
Father's Email Address
Your answer
Father's Occupation
Your answer
Marital Status
Brothers and Sisters (name & age)
Your answer
How did you find out about our preschool?
Your answer
Name of Church
What church, if any, are you a member of?
Your answer
Any Additional Comments?
Your answer
Emergency Information
We realize that many parents cannot be reached by phone during school hours. Hopefully the need for emergency treatment will not be needed, but should an accident occur, parental permission is required before any medical attention can be given. We will always try to contact parents by phone first. If they cannot be reached, we will contact the child's doctor and any emergency contacts listed.

The information below will help us give current and accurate information concerning your child to enable us to act quickly in case of an emergency. This form will also indicate who is authorized to pick up your child after school or in case of an illness. We will not release a child to anyone other than the parents or those indicated below without your permission.

Thank you.

Child's Doctor *
Your answer
Doctor's Phone *
Your answer
Doctor's Address *
Your answer
Emergency Hospital Preference *
Your answer
Special Needs of Child (allergies, fears, disabilities, etc)
Your answer
If parents cannot be reached in an emergency, please call the following first. *
Name and phone number for first contact
Your answer
If parents cannot be reached in an emergency, please call the following second. *
Name and phone number for second contact
Your answer
If parents cannot be reached in an emergency, please call the following third.
Name and phone number for third contact
Your answer
Person (other than Parents) authorized to pick up your child (1).
Name, relationship, and phone number
Your answer
Person (other than Parents) authorized to pick up your child (2).
Name, relationship, and phone number
Your answer
Person (other than Parents) authorized to pick up your child (3).
Name, relationship, and phone number
Your answer
Parent's Signature *
By signing this, you are consenting that the information is accurate.
Your answer
Date *
Your answer
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