EPWORTH PRE-SCHOOL 2 YEAR REGISTRATION
Child's Name*
First Name Middle Name Last Name
Birthdate*
mm/dd/yy
Name Teacher Should Call Your Child ?
Gender
Boy or Girl
Mother's Name*
First Name Middle Name Last Name
Does the child leave with both parents*
Yes/No
Mother's Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Father's Name*
First Name Middle Name Last Name
Father's Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Other members of household?
Name Age Relationship
Has child had previous school experience?
Yes/No
If yes, please give name of school(s)
Student Information
Student Information
Providing detailed information to the questions below will allow our teachers to work more effectively with your child. All information provided is kept in the strictest confidence.
1) Physical Restictions/Chronic Medical Conditions:
2) Dietary Restrictions or Food Allergies
My child has a restricted diet and cannot eat:
My child is allergic to the following and cannot eat:
My child is has a diagnostic of anaphylaxis:
Yes/No
Your Email

For Official Use Only

Registration Date: __________/______/________

W/D Date: _________/______/__________

Notes: _____________________________________

Amount Received: $ _________._____

Payment: ______ Check/Cash ___________ MC/Visa

Notes: _____________________________________

EPWORTH PRE-SCHOOL 2 YEAR REGISTRATION

Student Information