Greyhound Puppies Application(Please print, complete, and return to Mrs. Heiss at Northern Burlington HS, 160 Mansfield Rd. East, Columbus, NJ 08022.) NAME OF CHILD _________________________________________________________ NAMES OF PARENTS ______________________________________________________ ADDRESS ______________________________________________________________ _______________________________________________________________________ HOME PHONE NUMBER _____________________CELL ___________________ EMAIL ADDRESS ______________________________________________ AGE OF CHILD ____________ BIRTHDATE _________________________ FAMILY PHYSICIAN ___________________________________________ PHONE ___________________ EMERGENCY NAME & PHONE NUMBERS IN CASE PARENTS CAN NOT BE REACHED: NAME _____________________________PHONE _____________________ NAME _____________________________PHONE _____________________ PLEASE LIST ANY MEDICAL INFORMATION (ALLERGIES, MEDICATIONS, ETC.) THAT SHOULD BE KNOWN FOR THE DAILY CARE OF YOUR CHILD: ________________________________________________________________________ NAMES AND PHONE NUMBERS OF PERSONS AUTHORIZED TO TRANSPORT YOUR CHILD FROM SCHOOL: _______________________________________________________________________ ________________________________________________________________________ NAMES OF PERSONS NOT AUTHORIZED TO TRANSPORT YOUR CHILD FROM SCHOOL: ________________________________________________________________________ INDICATE SESSION: AM(9:15-11:15) __________ PM(12:15-2:15) _______ I hereby attest that the information given is true and give my permission for my child to participate in all activities in the Greyhound Puppies Preschool. I also give my permission for the school nurse to administer emergency treatment as necessary. Please send a physician's copy of shot records by the first day of school. SIGNATURE OF PARENT _________________________DATE ______________ Please return with tuition ($80 per 9-week session or $220 for full year) as soon as possible.
PERSONAL INFORMATION NAMES AND AGES OF CHILD'S SIBLINGS ________________________________ ______________________________ ________________________________ ______________________________ OTHERS LIVING WITH CHILD IN ADDITION TO PARENTS AND SIBLINGS: ________________________________ _____________________________ MOTHER'S OCCUPATION ______________________________________________ FATHER'S OCCUPATION ______________________________________________ WHICH WINTER HOLIDAY DOES YOUR CHILD CELEBRATE: _____ CHRISTMAS _____ HANUKKAH _____OTHER: ___________________ LIST YOUR CHILD'S FAVORITES: FOOD __________________________ TOY _______________________________ TV PROGRAM ____________________________ COLOR ____________________ CHILDREN'S PETS: ____________________________________________________ WHERE WAS YOUR CHILD BORN? ______________________________________ NATIONAL HERITAGE ________________________________________________ CHILD'S PRIMARY LANGUAGE ________________________________________ CHILD'S FEARS ____________________________________________________ CHILD'S STRENGTHS _______________________________________________ WHAT WOULD YOU LIKE YOUR CHILD TO LEARN THIS YEAR? _________________________________________________________________ ANY OTHER INFORMATION YOU WOULD LIKE US TO KNOW ABOUT YOUR CHILD? _________________________________________________________________
PLEASE SUBMIT THIS APPLICATION AS SOON AS POSSIBLE. WE ALSO NEED A COPY OF YOUR CHILD'S SHOT RECORDS - THIS MAY BE SUBMITTED WITH THE APPLICATION OR ON THE FIRST DAY OF SCHOOL.
SINCE WE LIKE TO HAVE OUR CHILDREN PARTICIPATE IN THEIR SCHOOL EXPERIENCE AS MUCH AS POSSIBLE, PLEASE ASK YOUR CHILD TO DRAW A PICTURE BELOW AS HIS OR HER "SIGNATURE." THANKS!
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