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PRESCHOOL REGISTRATION
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* Indicates required question
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Home Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Primary Phone Number
*
Your answer
Primary Parent or Guardian First Name
*
Your answer
Primary Parent or Guardian Last Name
*
Your answer
Primary Parent Employer's Name
Your answer
Primary Parent Employer's Phone Number
Your answer
Secondary Parent or Guardian First Name
Your answer
Secondary Parent or Guardian Last Name
Your answer
Secondary Parent Employer's Name
Your answer
Secondary Parent Employer's Phone Number
Your answer
Please Check All That Apply
Mother Living
Father Living
Married
Divorced
Seperated
If divorced, which parent has custody?
Mother
Father
Other:
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The registration fee is due at this time and checks can be made out to Ashland County-West Holmes Career Center Preschool
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