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Skowhegan Nursery School
Registration Form 2008-2009

[Confidential Information]

A $30 Registration 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 $30 registration 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)