Register Now – Noah’s Ark Preschool

Program you wish to enroll your child in *

3 year old program (TTH)
4 year old program (MWF)
4 year old program (Noah's Ark Plus)

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 *

Mother's Employer

Mother's Work Phone

Father's Name *

First

Last

Father's Cell Phone

Father's Employer

Father's Work Phone

In th event of an emergency, if we are unable to contact you, whom should we call? (Must provide two emergency contacts) *

First

Last

Emergency Contact #1 Phone Number *

Emergency Contact #1 Address *

Emergency Contact #1 City *

Emergency Contact #1 Zip Code *

Emergency Contact #2 *

First

Last

Emergency Contact #2 Phone Number *

Emergency Contact #2 Address *

Emergency Contact #2 City *

Emergency Contact #2 Zip Code *

The following people are authorized to pick up my child from preschool:

First

Last

Phone Number

Name

First

Last

Phone Number

Name

First

Last

Phone Number

Name

First

Last

Phone Number

Emergency First Aid *

Yes
No

I authorize the staff at Noah's Ark Preschool to administer basic first aid to my child(ren), 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(ren) 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)

Field Trips *

Yes
No

My child(ren) have my permission to attend field trips with Noah's Ark Preschool. All field trips will be announced prior to scheduled date and an adult chaperone will be required to attend with your child.

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.

Today's Date *

A non-refundable registration fee of $75.00 is due upon enrollment. Paperwork will be processed upon receipt of payment, which will secure your child's spot in our program.