Registration Name of Child: Nickname (if any): School year registering for: Age of child on October 15th of above year: M/F: Date of Birth: Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Phone (###) ### #### Parent #1/ Legal Guardian First Name Last Name Occupation Employer Bus. Phone (###) ### #### Cell Phone (###) ### #### Parent #2/ Legal Guardian First Name Last Name Occupation Employer Bus. Phone (###) ### #### Cell Phone (###) ### #### EMERGENCY CONTACT: In case of emergency when parents cannot be contacted, we may contact: Relationship to child Phone (###) ### #### Doctor Please enter the name of your Child's Doctor First Name Last Name Dentist Please enter the name of your Child's Dentist First Name Last Name PLEASE CHECK SESSION(S) YOU WISH TO ENROLL YOUR CHILD IN: TEDDY BEARS (ages 3-4) Tues/Thurs: 9:00-12:00 Tues/Thurs: 9:00-2:30 HONEY BEARS (ages 4-5) Mon/Wed/Fri: 9:00-12:00 Mon/Wed/Fri: 9:00-2:30 Early Drop off: 8:15-9:00 LIBRA MONTESSORI (ages 3-6) Mon-Thurs: 8:15-2:30 Mon-Fri: 8:15-2:30 Mon-Thurs: 8:45-1:00 Mon-Fri: 8:45-1:00 Special Requests: Names of people, other than parents, who may pick up your child from school. Include their relationship as well as how your child refers to them. (ie. Jane Doe, grandmother - Nana) Please list anyone who is not to pick up your child. We must have copies of any legal restrictions in your child's file. Names, ages and relationships of other members of your household: May we use your name, address email and phone number on the class list? This list will be distributed to classmates. Yes No Does your child have allergies, or are there foods he/she should not eat for any reason? Has your child previously, or is he/she currently seeing a doctor for an extended period of time for medical or psychological reasons or receiving any services (i.e. speech, OT, PT)? If yes, please explain. (Copies of IEP plans should be emailed or brought to school). Has your child had any experience in a formal program outside of the home (i.e. day care, other preschool, etc.)? How did you hear about our program? I hereby certify that, to the best of my knowledge, my child is physically and mentally able to participate in all of the activities at Highland Pre-School. I understand and agree to the arrangements for payment of tuition. Parent/Legal Guardian Signature First Name Last Name Thank you! Applications are not considered complete unless accompanied by the nonrefundable $75 registration fee ($25 for returning pre-schoolers). Pay your registration fee