Skowhegan Nursery School--Registration Form

Skowhegan Nursery School
Registration Form 2011-2012

[Confidential Information]

A $50 Registration/Materials Fee (non-refundable) is due at the time of registering; checks made payable to "Skowhegan Nursery School".

NOTE: If submitting this registration form online, the registration will NOT be considered complete until the $50 registration/materials fee is received by the Nursery School. Confirmation of the registration and payment will be mailed (or emailed) to the address given on the form.

Child's Information:

Child's Full Name

Preferred Name

Mailing Address

City State Zip

Physical Address (if different than mailing)

Date of Birth

Session(s): Choose your days from a minimum of 2-sessions per week to a maximum of 5-sessions per week. Sessions run daily from 8:30 - 11:30 a.m. First-come, first-serve basis.
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY

Month & Year of Enrollment

List of Allergies

Health Concerns/Conditions

Special Needs

Child's Physician

Child's Dentist

Family Information:

Mother's Name
Mother's Address
Mother's Place of Employment
Mother's Occupation
Mother's Home Phone   Work Phone   Cell Phone
Mother's Email Address

Father's Name
Father's Address
Father's Place of Employment
Father's Occupation
Father's Home Phone   Work Phone   Cell Phone
Father's Email Address

Sibling(s) Name(s):    Age:
                                     Age:
                                     Age:
                                     Age:
                                     Age:

Emergency Information:

1st Person to be notified in case of illness or accident Phone

2nd Person to be notified in case of illness or accident Phone

I hereby give the Skowhegan Nursery School staff permission to obtain emergency medical care if deemed necessary (please type name of legal guardian):

REFERRING FAMILY (if applicable)

Skowhegan Nursery School Registration Form 2011-2012

Skowhegan Nursery School
Registration Form 2011-2012