Child's Name Date of Birth Grade Entering
Church Affiliation (if any) Gender Male Female
Mother's Name Home Address
Home Phone Work/cell phone Email
Business Name/address
Father's Name Home Address
Child lives with: Both Parents Mother Father Guardian (name)
Care Needed:
Preschool Monday Tuesday Wednesday Thursday Friday Full Week
Afterschool Monday Tuesday Wednesday Thursday Friday Full Week
Full day on School recess (afterschool only) All Some None
Allergies:
Other relatives or friends who live with your child:
List your child's favorite activities, hobbies, sports, people, food, etc:
Afterschool students only: School attending Phone Bus # Teacher
______________________________________________________________________________
Authorization to Photograph
I give permission for my child to be photographed or video-taped during school activities/events for newspapers or other publicity.
Yes No Parent's Initials
