Registration Form

___Date Paid
Check #

Ms. Boedee’s Kinder Prep
2014-2015
Registration Form
A one-time registration fee of $25 is due at the time of registration.

Child’s Name_________________________________Name They Go By in School_______________________
Birthday____________________________
Mother’s Name__________________________

Father’s Name_____________________________________

Home Address______________________________________________________________________________
Home Phone___________________________

Mother’s Cell_______________________________________

Father’s Cell____________________________ Email Address_______________________________________
Emergency Contact Person(s)
Name________________________________________________ Phone______________________________
Name________________________________________________ Phone______________________________
Authorized Person(s) Who May Pick Up After School
Name_________________________________________________Phone_______________________________
Name_________________________________________________Phone_______________________________
Please list any allergies to medications, foods, or other substances, etc.
__________________________________________________________________________________________
Is there any food that your child won’t eat for snack?______________________________________________
I agree that the operator may authorize the physician of his/her choice to provide emergency medical care in
the event that neither I, my spouse, alternate contact(s), can be located immediately.
Parent’s Signature_______________________________________ Date_______________________________
Operator’s Signature_____________________________________ Date_______________________________