Registration Form
We agree to make all tuition payments by the 5th of the month. Choose one below. *
Please put the following initials below:
Father Initials *
Your answer
Mother Initials *
Your answer
Guardian Initials *
Your answer
Child Full Name *
Your answer
Child Age: *
Your answer
Birth date: *
Your answer
Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Mother Full Name: *
Your answer
Mother Cell Phone: *
Your answer
Mother Address *
Mother Occupation: *
Your answer
Mother Work Hours: *
Your answer
Mother Work Phone: *
Your answer
Mother Business Address *
Your answer
Father Full Name: *
Your answer
Father Cell Phone: *
Your answer
Father Address: *
Father Occupation: *
Your answer
Father Work Hours: *
Your answer
Father Work Phone: *
Your answer
Father Work Address: *
Your answer
Child Lives with *
If Guardian, Please fill out below.
Guardian Full Name
Your answer
Guardian Phone:
Your answer
Relationship to Child:
Permission to Pickup Child
The people that are authorized to pick up my child from The Door to Explore Preschool.
Full Name
Your answer
Phone:
Your answer
Relationship
Your answer
Full Name
Your answer
Phone:
Your answer
Relationship:
Your answer
Full Name:
Your answer
Phone:
Your answer
Relationship:
Your answer
Emergency and Medical Information
Emergency Contact 1 Full Name: *
Your answer
Phone: *
Your answer
Relationship *
Emergency Contact 2 Full Name: *
Your answer
Phone: *
Your answer
Relationship *
Please be specific and provide as much detail as possible along with a copy Immunization record.
Allergies: *
Your answer
Medications: *
Your answer
Other significant information: *
Your answer
Insurance company: *
Your answer
Group # *
Your answer
ID# *
Your answer
Phone# *
Your answer
Physician
Your answer
Phone
Your answer
Consent of Treatment
In case of emergency and I/We cannot be reach, any Door to Explore Preschool staff or representative have permission to seek emergency medical treatment on my child's behalf.
Parent/Guardian Digital Signature 1 *
Your answer
Parent/Guardian Digital Signature 2
Your answer
Today's Date *
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Door to Explore Preschool is a ministry at The Door Church
905 W 22nd St Laporte, IN 46350 Director Phone: 219-380-9067
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