Zion Lutheran Preschool Questionnaire

(Please Print or Type)

Name of Parents or Legal Guardian: ____________________________________________________

Student’s Address: _________________________________________________________________

Student’s Telephone Number: _________________________________________________________

Student’s Name: _______________________________Nickname: ___________________________

Student’s Age: _______ Student’s Birthday (mm/dd/yy): __________________

Baptized: Yes No (Circle One)

Home Church: ____________________________________________________________________

Address: ________________________________________________________________________

Father’s Occupation: __________________________ Telephone Number: ____________________

Address: ___________________________________ Cell or Beeper Number: _________________

Mother’s Occupation: _________________________ Telephone Number: ___________________

Address: ___________________________________ Cell or Beeper Number: _________________

Names of brothers and sisters and their birthdates:

1._______________________ 3._______________________ 5._______________________

2._______________________ 4._______________________ 6._______________________

Name of Physician: ____________________________ Telephone Number: ___________________

Are immunizations current? Yes_____ No_____ (If no, explain)

Does your child have any allergies? (If so, explain):

________________________________________________________________________________

Does your child have any handicaps? (If so, explain):

________________________________________________________________________________

What are some special interests of your child?

________________________________________________________________________________

How did you find out about our preschool program? ________________________________________

What elementary school will your child attend Kindergarten? __________________________________

Name two people to contact in case of emergency, other than yourself:

1.________________________Address_____________________________Telephone________________

2.________________________Address_____________________________Telephone__________________

Name of babysitter (If applicable):

Name_____________________Address_____________________________Telephone__________________

Who will be picking up your child from preschool?

(Please notify staff of any change daily or permanent):

_______________________________________________________________________________________________

I would be interested in Before Care or help with transportation. Explain:

____________________________________________________________________________

COMMENTS: _____________________________________________________________________

__________________________________________________________________________________

I would like to enroll my child in: (Check One)

_____Session I M-W-F 9:00 – 11:30

_____Session II M-W-F 12:30 – 3:00

_____Session III T-Th 9:00 – 11:30

_____Session IV T-Th 12:30 – 3:00

FOR OFFICE USE ONLY: Received ________________Check or Cash ________________

Session __________________Confirmation Sent_____________