My School Two Registration Form – Noah’s Ark Preschool

Child's Name *

First

Middle

Last

Nickname or Name Your Child Goes By

Address *

City *

Zip Code *

Phone Number *

Birthdate *

Sex *

Male
Female

Family Email *

Child's Religion

Parish

Mother's Name *

First

Last

Mother's Cell Phone

Father's Name *

First

Last

Father's Cell Phone

Emergency First Aid *

Yes
No

I authorize the staff at Noah’s Ark Preschool to administer basic first aid to my child, including but not limited to: CPR, cleaning of minor scratches and wounds, application of band-aids, and application of ice to bumps and bruises.

Emergency Medical Care *

Yes
No

I authorize Noah’s Ark Preschool to secure EMERGENCY medical care for my child when I cannot be immediately reached at the time of the emergency. I accept responsibility for the emergency medical charges upon receipt of the statement.

Physician Information

First

Last

Address

Phone Number

Preferred Hospital

Northwestern Medical Center 815-344-5000
Good Shepherd Hospital 847-381-9600
Other (Please provide name and phone number of hospital below)

How did you hear about Noah's Ark Preschool? *

Verification of Receipt of Handbook *

Yes
No

I have read and fully understand the Noah’s Ark Preschool Parent Handbook. I understand I may approach the director or other staff members with any questions I may have.