First Presbyterian Preschool

2005 - 2006 Registration Form

Child's Name ( first, middle, last ) _____________________________________

Nickname _______________________________

Address ____________________________________________  Zip Code _____________

Child's Date of Birth _____________

Parents or Guardians

Name ____________________________________ Relation to Child _________________________

Occupation ____________________________________________

Phone Number ________________________   Mobile ________________________

Name ____________________________________ Relation to Child _________________________

Occupation ____________________________________________

Phone Number ________________________   Mobile ________________________

Status of Parents ( Check ):   Living together ___      Living apart ___

If parents work, who keeps the child in their absence?

Name ______________________________

Relation to child ________________________

Phone Number _____________________    Mobile ____________________

Other children in the family: ( Names & Ages )  ___________________________________

_______________________________________________________________________

If any other person is authorized to pick up your child, we will need their names and phone numbers.  We will not release your child to any person who has not been authorized by a parent.

Name & Phone   _________________________________________________

Relation to child  _________________________________________________

Name & Phone  _________________________________________________

Relation to child  _________________________________________________

Mail to:  First Presbyterian Church, Preschool,  P.O. Box 1075, New Bern, N.C.  28563