NOAH’S RAINBOW PRESCHOOL REGISTRATION FORM
Wesley United Methodist Church, Strasburg, PA 17579 (717) 687-6392
(Please complete both sides.)
Child’s Name ______________________________________ Nickname__________________________
Address_____________________________________________________________________________
Street City Zip
Telephone Number________________________ Birthday _______/_______/_______ Sex: M F
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Circle Class Choice
2 Year Old Class: Option #1 MW 9:00 – 11:00 AM
3 Year Old Class: Option #1 MW 9:00 – 11:30 AM OR Option #2 TTH 9:00 – 11:30 AM
Pre-K Class: Option #1 TTH 9:00 – 11:30 AM OR Option #2 MWF 9:00 – 11:30 AM OR
Option # 3 MWF 12:30 – 3:00 PM OR Option #4 M to F 9:00 – 11:30 AM
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Parent Information
Name________________________________________________________________________________ Address______________________________________________________________________________
Phone____________________________ Alternate Phone______________________________________
Name________________________________________________________________________________
Address______________________________________________________________________________
Phone___________________________ Alternate Phone_______________________________________
Family Information
Names and ages of Siblings_______________________________________________________________
Parents are: _______both at home ________divorced ______remarried
_______father deceased ________mother deceased
Emergency Contact Information
Name________________________________________________________________________________
Address______________________________________________________________________________ Phone_______________________________ Alternate Phone__________________________________
Relationship to Student__________________________________________________________________
List anyone who may NOT have contact with your child
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Immunization Records -- Please provide us with a copy of your child’s records from his/her physician. (Only required for new students. Current students’ records are on file.)
The following immunizations are recommended by the CDC.
Hepatitis B Rotavirus DTaP Hib Pneumococcal
IPV MMR Varicella Hepatitis A Yearly Influenza
Medical Information
List all allergies (food, medicines, and other) _______________________________________________
List any medical conditions _____________________________________________________________
List all medications taken on a regular basis ________________________________________________
Is the child potty trained? YES NO IN PROCESS
List any concerns with toilet training ______________________________________________________
List any emotional concerns _____________________________________________________________
List any speech or hearing concerns _______________________________________________________
Physician Information
If you or your emergency contact cannot be reached in case or a medical/dental emergency, we will contact the medical center of your choice, or call 911 if necessary. Please fill in the following information and sign to give us permission to do so.
Physician’s Name______________________________________________________________________
Address______________________________________________________________________________
Phone________________________________________________________________________________
Dentist’s Name________________________________________________________________________
Address______________________________________________________________________________
Phone________________________________________________________________________________
Hospital Preference_____________________________________________________________________
Parent Signature__________________________________________________Date_________________
Additional Information
Please list any additional information about your child that you think may be helpful to the teacher.
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