Preschool Registration Form – Hazelwood Christian Church, Muncie, Indiana

Student Information

Student's Name *

Date of Birth *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Any additional information we should know (i.e. allergies), please include it here:

Mother's Name *

Child Pickup Okay? *YesNo

Is mother's address is the same as the student's? *YesNo

Street Address

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Mother's Phone Number(s)

Phone *

Is this a cell, home, or work number? *CellHomeWork

Mother's Email Address

Father's Name *

Child Pickup Okay? *YesNo

Father's Phone Number(s)

Phone *

Is this a cell, home, or work number? *CellHomeWork

Is father's address is the same as the student's? *YesNo

Street Address

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Father's Email Address

1st Choice *

2nd Choice *

Emergency/Pickup Contacts

Name *

Relationship to Student *

Please indicate if this person is allowed to pickup the student and/or should be contacted in case of an emergency *PickupEmergency

Phone Number *

Is this a cell, home, or work number? *CellHomeWork