Name of Student

Name of Parent(s)

Address

Employment Information

Contact Information: Home/Cell

Contact Information: Work

Emergency Contact Info (If you are unavailable)

Student Date of Birth/Age

Please Choose One M/W/F 8:30 - 12:30 M/W/F 12:30 - 3:30 Tues/Thurs 8:30 - 12:30 Tues/Thurs 12:30 - 3:30

Please list all allergies and/or medical concerns we should be aware of including medication taken at home and/or school:

Please provide medical contact information for your child. Include name of doctor, hospital, phone numbers and addresses.

What would you like to see your child achieve this year?

When do you think your child will be ready to learn to read?

Please share any other information that you think will help us enrich your child's educational experience this year!

I have included the enrollment fee with the enrollment form: __Y__N Yes No

Parent Signature/Authorization Agree Disagree

Thank you for choosing Happy Hearts Preschool - The school with a heart and vision for future generations!

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