Child’s Full Name:
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Nickname:
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Gender:
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Age:
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Date of Birth:
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Address:
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Home Phone:
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E-mail address:
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Father’s Name:
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Cell Phone Number:
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Home Address (if different):
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Work Address & Phone:
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Mother’s Name:
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Cell Phone Number:
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Home Address (if different):
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Work Address & Phone:
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Does the child live with both parents? Yes No If not, with which parent will the child be living while attending playschool?
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Person responsible for child if parents are unavailable:
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Name:
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Relationship:
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Address
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Phone Number:
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Who will be picking up your child after Playschool?
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Please list all names of people authorized to take your child from playschool:
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Name:
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Relationship:
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Telephone:
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Name:
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Relationship:
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Telephone:
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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?
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Child’s Physician:
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Telephone:
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Does your child have any allergies? If so, please list:
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Is there any previous medical history that would affect your child’s participation in activities? Explain:
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Is your child toilet-trained?
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Describe your child briefly. Tell about favorite toys, daily routines, interests, etc.
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What are you hoping for your child to gain by his/her experience in our playschool program?
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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
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May we use photos/video that include your child for public relations purposes in local newspapers, Newark CS website or broadcasts? _____ Yes OR _____ No
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HAVE YOU REMEMBERED TO ATTACH A COPY OF YOUR CHILD’S IMMUNIZATION RECORDS?
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