Kidz Korner Enrollment Information Form

Kidz Korner Enrollment Information Form

Name of child ______

first middle last

Name your child goes by (Ben instead of Benjamin, Sam instead of Samantha) ______

Age______Birth date ______

Home Address______

street city zip

Home Telephone Number ______Email Address ______

Father’s Name______Work Place ______

Occupatoin ______Work Phone # ______

Cell Phone # ______Best way to contact______

Mother’s Name ______Work Place ______

Occupation ______Work Phone # ______

Cell Phone # ______Best way to contact______

Emergency name and number of other adult if parent can not be reached:

______

Name and number of child’s doctor

______

Who will regularly transport your child to and from Kidz Korner?

______

Does your child have any health problems or allergies? YES NO

If so, please explain

______

Please list foods your child dislikes

______

Is your child toilet trained? (This is not a requirement.) YES NO

Sibling’s Name(s) and ages ______

If your family has pets, please list type and name.

______

What are your child’s favorite activities and toys?

______

Does your child have any fears, dislikes, or things that disturb him/her that you’d like me to be aware of? (Miss Stacy will bring her small dog occasionally unless your child has a fear of dogs.)

______

Does your child have frequent playmates other than siblings? YES NO

Does your child participate in any social activities with children hs/her age? (i.e. Library Story Time, Sunday School, gymnastics, playgroup) YES NO If so, what______

Is your child apprehensive about preschool? YES NO

Has your child attended preschool previously? YES NO

If your child has previously attended preschool, please explain why you are enrolling in Kidz Korner.

______

Is there anything that you can tell me about your child’s personality that would help me to better understand him/her? (i.e. strengths, weaknesses)

______

______

______

Please list any specific things you’d like your child to learn at preschool or gain from this experience.

______

______

______

Comments/suggestions/ questions

______

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