Building Blocks Preschool

Registration Form
Name of Child: __________________________Preferred name__________________
Birth Date: ________________ Age as of Dec. 31, 2017 ______ Gender (M/F) ______
Parent/Guardian Name(s): _______________________________________________
Street Address: ___________________
______________________________

Mailing Address (please include postal code):

____________________________________

Home Phone: ____________________Work Phone: ___________________________

Email address: _________________________________________________________
Moms Cell: _______________________ Dads Cell: ____________________________
Alternate Contact and Phone: _____________________________________________
1. What is your preferred time? Please indicate your 1st and 2nd choices:
o Twice per week (4 yr olds): Tue/Thu am_____ Tue/Thu pm _____
o Once per week (3 or 4 yr olds): Wed pm _____
o Once per week (3 yr olds): Wed am ______
2. Name of child you would like to be in the same class with (optional please note not
all requests can be granted): ______________________________________________
3. May we include your name and phone number on the student list? Yes or No

4. Allergies, health or other concerns:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
5. Doctors name and phone number: _______________________________________
6. Saskatchewan Health Number (for medical emergencies) ______________________
7. Is your childs tuition to be paid from an outside source such as Family Services, or
Early Entrance programs? Yes___ No ___
(To protect your privacy the Administrator will contact you for your information.)

*OFFICE USE ONLY*

Day(s) Child is attending __________________________________________ AM/ PM
$30 Registration Fee Collected
Monthly postdated cheques
Full year payment
Half a year payment Sept-Dec
Half a year payment Jan-May
Other