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Lil’ reds playschool


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LIL’ REDS PLAYSCHOOL


REGISTRATION SHEET
FAMILY & CONSUMER SCIENCE DEPARTMENT

CHILD PSYCHOLOGY CLASSES



NEWARK HIGH SCHOOL
Please complete this form and return it to: Mrs. Barbara Mikler-Crandon

Newark High School

625 Peirson Ave.

Newark, NY 14513


Child’s Full Name:

Nickname:

Gender:

Age:

Date of Birth:

Address:

Home Phone:

E-mail address:

Father’s Name:

Cell Phone Number:

Home Address (if different):


Work Address & Phone:

Mother’s Name:

Cell Phone Number:

Home Address (if different):


Work Address & Phone:

Does the child live with both parents? Yes No If not, with which parent will the child be living while attending playschool?


Person responsible for child if parents are unavailable:

Name:


Relationship:

Address

Phone Number:


Who will be picking up your child after Playschool?



Please list all names of people authorized to take your child from playschool:

Name:


Relationship:

Telephone:

Name:


Relationship:

Telephone:

In the event of an emergency cancellation of Lil’ Reds Playschool, what is the best number to reach you at on the morning of a session to make you aware of a cancellation?





Child’s Physician:

Telephone:


Does your child have any allergies? If so, please list:


Is there any previous medical history that would affect your child’s participation in activities? Explain:

Is your child toilet-trained?



Describe your child briefly. Tell about favorite toys, daily routines, interests, etc.


What are you hoping for your child to gain by his/her experience in our playschool program?



In the past, I have often had parents request a list of names/addresses/home phone numbers of the children in order to arrange “playdates.” Do you wish to include your child’s information on a “buddy list” to be shared with the parents of our Lil’ Reds Playschool participants this semester? PLEASE CHECK ONE:
_____ Yes, include our contact information OR _____ No, we do not wish to be listed

May we use photos/video that include your child for public relations purposes in local newspapers, Newark CS website or broadcasts? _____ Yes OR _____ No




HAVE YOU REMEMBERED TO ATTACH A COPY OF YOUR CHILD’S IMMUNIZATION RECORDS?


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