In His Steps Preschool Registration

Enter Child's Information Below:

Child's Name (First Middle Last)*:

Child's Nickname*:

Child's Birthdate*:

Child's Gender:

Has your Child been Potty Trained?:

Enter Family Information Below:

Street Address*:

City*:

State*:

Zip*:

Email Address*:

Home Phone*:

Church your family is currently attending:

Mother's Name*:

Mother's Employer:

Mother's Work Phone:

Mother's Cell Phone:

Father's Name*:

Father's Employer:

Father's Work Phone:

Father's Cell Phone:

Emergency Contact Information:

Emergency Contact*:

Emergency Contact Phone*:

Relationship to Student:

2nd Emergency Contact*:

2nd Emergency Contact Phone*:

Relationship to Student:

Person(s) authorized to pick up my child:

Medical History:

Please indicate whether your child has struggled with any of these conditions. Also indicate the age when they were affected. This information is used solely as a medical reference for our staff. It has no bearing on enrollment eligibility.

Asthma:

Chicken Pox:

Heart Disorder:

Measles:

Rubella:

Pneumonia:

Whooping Cough:

Diptheria:

Mumps:

Other:

Food Allergies:

Allergies:

Seizures:

Actions to take in case of an emergency (in regard to any of the information indicated above):

IMMUNIZATION FORM REQUIRED WITHIN 2 WEEKS OF SCHOOL’S BEGINNING

Emergency Medical Authorization:

In the event of a medical emergency, I/we the parent(s)/guardian of this child hereby give permission to IN HIS STEPS PRESCHOOL MINISTRY to render any necessary emergency medical treatment. In the event that I cannot be reached and my child needs emergency treatment, I authorize an attending physician at the nearest emergency room to administer necessary treatment to my child. I agree to assume all financial responsibility. I will hold In His Steps Preschool and it’s staff, Good Shepherd Baptist Church and it’s staff, Board of Overseers and Deacons, and the Southern Baptist Convention harmless for any accident or injury that may occur to my child while attending In His Steps Preschool Ministry.

Do you agree with the medical disclaimer:

Insurance Company Name:

Insurance Policy Number:

Child's Physician:

Physician's Phone:

Photograph Authorization:

In consideration for the valuable childcare services provided by In His Steps Preschool, I/we authorize Good Shepherd Baptist Church, In His Steps Preschool, their agents, their employees, and their assignees to photograph my child/children and to display the likeness of my child/children in promotional material, including print and Internet advertisements.

Do you agree with this authorization:

Comments/Questions

How did you hear about "In His Steps Preschool?"*: