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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Mother Name * Cell Phone * Employer Work Phone Address Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal E-mail * Father Name * Cell Phone * Employer Work Phone Address Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal E-mail * Names of other programs child has attended: Our Family Attends: (Name of Church) Names and Ages of Brothers and Sisters: Name Age Add 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 handicaps: 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! *** If you are human, leave this field blank. Next
