Centennial Preschool
2007-2008 Registration Form
Name ________________________________________ Birthdate ________
(First) (Middle) (Last)
Address _______________________________________________________
______________________________________________________________
Home Phone ________________ Email __________________________
Mother's Name _____________________________ Cell Phone __________
Employer _________________________________ Work Phone _________
Father's Name _____________________________ Cell Phone ___________
Employer ________________________________ Work Phone __________
IN CASE OF AN EMERGENCY, PARENTS WILL BE NOTIFIED FIRST; HOWEVER, TWO ALTERNATES ARE NEEDED IF FOR ANY REASON PARENTS CANNOT BE REACHED.
Emergency Contact _____________________________________________
Phone ___________________ Relationship to child ____________________
Emergency Contact _____________________________________________
Phone ___________________ Relationship to child ____________________
Other Children in the family:
Name ______________________________________ Age ______________
Name ______________________________________ Age ______________
Name ______________________________________ Age ______________
Church Home__________________________________________________
Child's Doctor ______________________________ Phone ______________
Child's Dentist ______________________________ Phone _____________
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Registration Fee: (Per Returning Family) $35.00 New Family $40
Supply Fee: (per child) $65.00
These fees are due upon registration and are nonrefundable after June 1st.
__________________________________________
(Signature of Parent of Guardian)
I am registering for: M/W/F Class_____ T/TH Class_____ MDO--Day_____
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For office use: Date of check ________ Check Number ________ Check Amount _________
