* = Required Information
Child's Name
*
Birth Date
*
Sex
*
Male
Female
Enrollment Date
Child lives with
Mother
Father
Both Parents
Mother's Name
Phone
Cell Phone/Pager
Mother's Address
Mother's Employer
Phone
Father's Name
Phone
Cell Phone/Pager
Father's Address
Father's Employer
Phone
Mother's SSN
Father's SSN
In the event we cannot reach either parent, we required a third person emergency contact:
Name
Phone
Relationship to Child
Child's Physician
Address
Phone
Name of Hospital Preferred
Authorization of emergency medical care in the event of serious illness or accident if parents cannot be reached
Parents Statement: Special information relating to food, medication, toilet training, sleep requirements and/or emotional needs
*
I agree to comply with the rules and regulations of The Learning Tree Preschool regarding fees, attendance, illness policies and other items specified in the policies issued by the school year. I am aware of the scheduled school holidays and closings. I agree to notify the school two weeks in advance of withdrawal, shoulc such event occur or pay the difference.
Parent Name
*
Date
Submit