Please ensure all required fields are completed. Fields marked with an * are required
First Name
Last Name
Gender
MaleFemale
Address/PC:
AB Health:
Date of Birth
Select MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Select Year1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020
City
Home phone:
Parent 1 First Name
Parent 1 Last Name
Parent 1 Address:
Parent 1 City:
Parent 1 Postal code
Parent 1 Email:
Parent 1 Work phone:
Parent 1 Home phone:
Parent 1 Cellphone:
Parent 2 First Name
Parent 2 Last Name
Parent 2 Address:
Parent 2 City:
Parent 2 Postal code
Parent 2 Email:
Parent 2 Work phone:
Parent 2 Home phone:
Parent 2 Cellphone:
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Address:
Zip / Post Code
Emergency Contact City/PC
Emergency Contact Relationship:
Emergency Contact Main phone
Emergency Contact Work phone:
Emergency Contact Alternate phone:
Has your child been immunized?
YesNo
Does your child have any allergies?
Is your child taking any medication on a regular basis? (e.g. epi-pen, insulin)
Does Your Child Have Physical Disabilities?
Does Your Child Have Medical Issues?
Is there any other important health information?
Additional Health Information:
Allergen(s):
Symptom(s):
Procedure:
Preferred Class Choice (First Class)
3-Year-Old AM - No teacher Preference3-Year-Old PM - No teacher Preference4-Year-Old AM - No teacher Preference4-Year-Old PM - No teacher Preference3-Year-Old AM - Ms. Keuhn3 Year-Old AM - Solecki3-Year-Old PM - Ms. Keuhn3 Year-Old PM - Solecki4-Year-Old AM - Ms. Keuhn4-Year-Old AM - Solecki4-Year Old PM - Ms. Keuhn4-Year Old PM - Solecki
Secondary Class Choice
3-Year-Old AM - No Teacher Preference3-Year-Old PM - No Teacher Preference4-Year-Old AM - No Teacher Preference4-Year-Old PM - No Teacher PreferenceNo Secondary Class Chosen3-Year-Old AM - Ms. Keuhn3-Year-Old AM - Solecki3-Year-Old PM - Ms. Keuhn3 Year-Old PM - Solecki4-Year-Old AM - Ms. Keuhn4-Year-Old AM - Solecki4-Year-Old PM - Ms. Keuhn4-Year-Old PM - Solecki
How have you heard about us?
As we are a volunteer run preschool, we ask that parents assist where they can. Please tell us how you would like to help the preschool? Ex) board member, fundraising assistance, casino volunteer etc.
PresidentVice PresidentSecretaryTreasurerSpecial EventsCasinoWebsite / Social MediaNot Interested
Medical Emergency Consent
I, hereby give authority for my child’s teacher to take the necessary steps to ensure that my child receives the care needed in any medical emergency. I also understand that I would be contacted immediately when any care is required. Please be aware that, in the event that 911 is called and an ambulance is dispatched, the parents will incur any related costs.
Personal Information Consent
I, hereby give permission for the preschool to publish my child’s full name and phone number for the purpose of providing class lists to currently enrolled families.
