Peace in Christ
Hermantown, MN
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Preschool
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Required fields are marked
*
Class Choice
Class Choice
Class
*
Please indicate 2nd class choice in the event a class reaches full capacity
Child Information
Child Information
Child's Name (First)
*
(Middle)
(Last)
*
Male / Female
*
Male
Female
Child's Address
*
Child's Date of Birth
*
Child's Age on First Day of School
*
Must be at least 33 months
Parent Information
Parent Information
Mother
Mother's Name (First)
(Last)
Mother's Address (if different than child)
Telephone Numbers: Home #
Cell #
Place of Employment/Occupation
Work #
Mother's email
Father
Father's Name (First)
(Last)
Father's Address (if different than child)
Telephone Numbers: Home #
Cell #
Place of Employment/Occupation
Work #
Father's email
Authorized Persons to Pick-up Child (must complete in full)
Authorized Persons to Pick-up Child (must complete in full)
Authorized Person 1
Name
*
Relationship
*
Phone #
*
Authorized Person 2
Name
Relationship
Phone #
Emergency Contacts (must list two persons and complete in full)
Emergency Contacts (must list two persons and complete in full)
Emergency Contact 1
Name
*
Relationship
*
Address
*
Home Phone #
Work Phone #
Cell #
Emergency Contact 2
Name
*
Relationship
*
Address
*
Home Phone #
Work Phone #
Cell #
Medical and Personal Information
Medical and Personal Information
Does your child have any food intolerances or sensitivities?
*
No
Yes
If yes, please explain and discuss with teacher:
Does your child have any diagnosed allergies?
*
No
Yes
If yes, please explain and discuss with teacher:
Are there any significant medical needs for your child?
*
No
Yes
If yes, please explain and discuss with teacher:
Are there any restrictions of activities?
*
No
Yes
If yes, please explain and discuss with teacher:
Does your child have an Individual Education Plan (IEP) or any individual child care program (ICCP) needs?
*
No
Yes
If yes, please consult with the teacher and attach a copy.
Is there any additional medical/personal/emotional information we should know about your child or family?
Does your child have any siblings?
*
No
Yes
If yes, please list names and ages:
Who does your child live with?
Mom
Dad
Other
Other, please explain:
What is your faith background? (Religion, church home, etc.)
Physician, Dentist and Insurance
Physician's Name
Phone #
Physician's Address
Hospital Preference
Medical Insurance Company
Group #
Dentist's Name
Phone #
Dentist Address
Dental Insurance Company
Group #
Emergency Medical Care Authorization
Emergency Medical Care Authorization
I have read and agree
*
Child's name
*
Acknowledgement of Registration Fee
Acknowledgement of Registration Fee
I have read and agree
*
Signature of Parent or Guardian (type your full name)
*
Date
*
Permission Form
Permission Form
Child's Name
*
Date of Birth
*
Signature of Parent or Guardian (type your full name)
*
Date
*
Submit Enrollment Form
