St.

Philip Preschool
&
St. Philip Lutheran Church
1790 Fort Street
Trenton, Michigan 48183

ST. PHILIP
PRESCHOOL

REGISTRATION FORM

Childs name:

www.stphilipelca.org | stphilipelca@gmail.com

Childs Full Name

____________________________________________________________________

Childs Nickname

_____________________________________________________________________

Date of Birth

__________________________

Desired session : 3yr ________ 4 yr ________

Fathers Full Name ________________________________________________________

Fathers Address

__________________________________________________________________________

City ______________________________ State _____________________ Zip Code ____________________

Phone Number _______________________________ Cell Phone Number ______________________________
Place of Employment ___________________________ Work Phone Number ______________________________
Hours of Employment __________________
Mothers Full Name ________________________________________________________
Mothers Address

__________________________________________________________________________

City ______________________________ State _____________________ Zip Code ____________________

Phone Number _______________________________ Cell Phone Number ______________________________
Place of Employment ___________________________ Work Phone Number ______________________________
Hours of Employment ____________________

Two other people who can be reached in case of emergency

Name ________________________________________ Name _______________________________________
Address ______________________________________ Address _______________________________________
___________________________________________
___________________________________________
Phone Number ________________________________ Phone Number _________________________________
Cell Phone Number _____________________________ Cell Phone Number ______________________________

Childs Physician _________________________________________________________________________________

Address ___________________________________________________ Phone _______________________________

Any medical information concerning child or which we should be aware of: (allergies, health problems etc)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Does child have any nervous habits? If yes, please explain below
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Any unusual experiences in the childs life that might affect his/her adjustment? If yes, please explain below
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Childs favorite play activities : ______________________________________________________________________

Does your child need special help in any areas? ________________________________________________________
Status of parents: ____ Married ____ Divorced ____ Single ____ Separated ____ Spouse deceased ____ Other
Names and ages of brothers _______________________________________________________________________
Names and ages of sisters _________________________________________________________________________
Other living at home ______________________________________________________________________________

Name, addresses and phone numbers of people who are authorized to pick up the child from St. Philip preschool

Name ___________________________________________________________________
Address ____________________________________________________________________________________
Phone Number _______________________________ Cell Phone Number ______________________________

Name ___________________________________________________________________
Address ____________________________________________________________________________________
Phone Number _______________________________ Cell Phone Number ______________________________

Name ___________________________________________________________________
Address ____________________________________________________________________________________
Phone Number _______________________________ Cell Phone Number ______________________________

Name ___________________________________________________________________
Address ____________________________________________________________________________________
Phone Number _______________________________ Cell Phone Number ______________________________