Early Childhood Development "Little Raiders" Registration Request 2019-2020 School Year
Applications are accepted on a first come first serve basis.
Please forward a copy of your child's immunization records to:
Keyport High School
Attention: Dawn Racioppi/Early Childhood Development "Little Raiders" Registration
351 Broad Street, Keyport, NJ 07735
Email Address: *
Your answer
Date of Immunization *
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Child's Name (Last, First, Middle) * *
Your answer
Date of Birth (Must by Three by 10/1/19) * *
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Male/Female *
Parent/ Guardian 1: *
Your answer
Parent/Guardian 2: *
Your answer
Parent/ Guardian 1 Cell Number: *
Your answer
Parent/ Guardian 2 Cell Number: *
Your answer
Home Address *
Your answer
Emergency Contact in case Parent/Guardian cannot be reached (please include their relationship to the child): *
Your answer
Does your child have medical concerns or learning disabilities that we should be aware of? *
Your answer
Does your child have allergies? If so to what? * *
Your answer
Any comments that will help us better understand your child (ex: personality traits). *
Your answer
Siblings? Age, Gender, School? *
Your answer
How did you hear about the program?
Your answer
What are your child's favorite toys? Or things to play with?
Your answer
What other organized activities is your child involved in (soccer, gymnastics, preschool, etc)?
Your answer
Has your child had opportunities to play/interact with other children? (Library groups, play dates) Do they play well with other children?
The session offered now is 8:30 a.m. to 1030 a.m. Is this a good time for you? *
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