NOAH’S RAINBOW PRESCHOOL REGISTRATION FORM
Wesley United Methodist Church, Strasburg, PA 17579 (717) 687-6932
(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: 3 Year Old Class:
Friday Option #1 MW Option #2 TTH
9:00 – 11:00 AM 9:00 – 11:30 AM 9:00 – 11:30 AM
4 Year Old (Pre-K) Class:
Option #1 TTH 9:00 – 11:30 AM Option #2 MWF 12:30 – 3:00 PM
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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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