Information Sheet

Kids Under Construction Preschool Information Sheet
Child's name
Gender:
Nickname to be used at school
Date of birth:
 /  / 

Mother's Information

Name:
Employer:
Phone (h):
-
Phone (w):
-
Phone (cell):
-

Father's Information

Name:
Employer:
Phone (h):
-
Phone (w):
-
Phone (cell):
-
Does the child live with both parents?

Mailing Address:
Is the child in the care of someone other than the parents during the day?
Caregiver's name:
Caregiver's phone:
-

Does the child speak a language other than English at home?
If yes, what language?
Please enter your child's allergies below:
List any medical concerns:
Is your child fearful of new situations or reluctant to leave parents?
Please add any comments that will help us get to know your child:
I give permission for my child to be transported and to participate in field trips during the school day. (parents may attend too)

I also give permission for my child to participate fully in the Kids Under Construction Preschool program.

Parent or guardian name

I give permission for photographs of my child/children to be used for preschool websites, newsletters, slide show and publicity purposes.


Parent or guardian name
Name of Child:
Birthdate:
 /  / 
Name of parents or guardians
Home phone:
-
Cell phone:
-
Please add any medical concerns or allergies:
I authorize the staff members of Kids Under Construction Preschool, Inc. to obtain immediate medical care for my child. I consent to the hospitalization of, the performance of necessary diagnostic testing, the use of surgery on, and the administration of medication to my child by medical staff if an emergency occurs. It is understood that this agreement covers only the treatment deemed necessary by a physician or emergency personnel when the parent or guardian can not be reached.

Please check one:
      Insurance company name
      Policy number:


Parent or guardian name