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ENROLLMENT FORM
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CHILD'S NAME (First, Middle, Last)
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Level Entering Into
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BIRTH DATE
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MAILING ADDRESS
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MOTHER'S NAME
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MOTHER'S ADDRESS (only if different)
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MOTHER'S PHONE NUMBER
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MOTHER'S EMAIL ADDRESS
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FATHER'S NAME
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FATHER'S ADDRESS (only if different)
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FATHER'S PHONE NUMBER
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FATHER'S EMAIL ADDRESS
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SIBLINGS (Names & Ages)
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NAME OF EMERGENCY CONTACT OTHER THAN PARENT
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RELATIONSHIP OF EMERGENCY CONTACT
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EMERGENCY CONTACT PHONE NUMBER
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EMERGENCY CONTACT ADDRESS
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PLEASE LIST ALL PEOPLE (other than parent) WHO ARE ALLOWED TO PICK UP YOUR CHILD FROM PRESCHOOL
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HOME CHURCH (if applicable)
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PLEASE TELL US ABOUT ANY ALLERGIES, SPECIAL MEDICAL CONDITIONS, (Including Chronic Health Problems or Disabilities) SPECIAL MEDICATIONS, AND/OR RESTRICTIONS:
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