.WESTSIDE BAPTIST CHURCH KINDERGARTEN

 

FOOD ALLERGY:_____________________________________________________________

 

Child's Name___________________________________________________________________

 

Name likes to be called _________________________Hand Preference___________________

 

Address:______________________________________________________________________

 

     City:___________________________State______________________Zip_______________

 

Phone_________________________________Date of Birth_____________Sex_____________

 

Mother's Name____________________________________Occupation____________________

 

     Business Name________________________________Phone_________________________

 

     Business Address____________________________________________________________

 

Attends Church at______________________________________Member?_________________

 

Father's Name____________________________________Occupation____________________

 

     Business Name________________________________Phone_________________________

 

     Business Address____________________________________________________________

 

Attends Church at______________________________________Member?_________________

 

Child lives with:     _____Mother & Father     _____Mother only

                           _____Father only             _____Guardian

 

Names and Ages of Brothers and/or Sisters

________________________   _______________________   ___________________________

________________________   _______________________   ___________________________

 

Does child have any mental or physical handicaps?__________If so, please explain_________

______________________________________________________________________________

Is child presently on any regular medication such as insulin, etc...?_______________________

Does your child have any allergies?_________________________________________________

If neither parent can be reached, please give names and phone numbers of at least two people we are authorized to call:

NAME_________________________________________Phone__________________________

 

NAME_________________________________________Phone__________________________

 

In case of emergency what doctor would you prefer us to call?

Name_________________________________________Phone___________________________

 

List names of those authorized to transport child to and from school:

_________________________   _____________________________   _________________________   _____________________________

_________________________   _____________________________   _____________________

 

Is there any other information which would be beneficial to us in further understanding your child?

____________________________________________________________________________________________________________________________________________________________