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
MM
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DD
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YYYY
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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