Student Information Form Enrollment Form (Ages 2-5) Child’s Information First Name * Last Name * Answers to * Date of Birth * Present Age * Sex * Male Female Family Information Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Mother Name * Cell Phone * Employer Work Phone Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal E-mail * Father Name * Cell Phone * Employer Work Phone Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal E-mail * Names of other programs child has attended: Our Family Attends: (Name of Church) Primary Language Spoken at Home * Names and Ages of Brothers and Sisters: Name Age plus1 Add minus1 Remove Child’s Living Arrangements: * Both Parents Mother Father OtherOther Are Parents Divorced? Death of Which Parent? When: Child’s Legal Guardians (if not parents) Do Legal Guardians have a Custody order? Can you provide a copy? Medical History Can you provide an up to date immunization record? No Yes When was your child’s last well check-up? * Any evidence of hearing loss? No Yes Vision Difficulties? No Yes Please list any physical or mental disabilities: Special health accommodations: Social and Physical Growth Right or Left Handed Left Right Does he/she talk well? No Yes Shy? No Yes Unusal Fears? What are some of the ways he/she plays at home? Favorite Games Favorite TV programs? Favorite foods? Favorite Toys? Does he/she play well with other children? No Yes Special Interests? How often do you read to your child? Do you visit a library? No Yes Methods of dicipline used with your child? In what ways do you expect this program to help your child? *** NOTE: THIS INFORMATION IS FOR THE TEACHERS USE ONLY; IT WILL BE KEPT IN CONFIDENCE! *** Next If you are human, leave this field blank.
