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Application
Child's Last Name
Child's First Name
Gender
DOB
Age
Father's Name
Mother's Name
Father's Phone # (Home)
Father's Phone # (Cell)
Father's Phone # (Work)
Mother's E-Mail
Mother's Phone # (Home)
Mother's Phone # (Cell)
Mother's Phone # (Work)
Father's E-Mail
Home Address
City
State
Zip Code
Does your child take medication or have allergies? If yes, explain the type of allergies and or reason for medication. Please list any serious injuries, illnesses or hospitalizations.
Is Your Child Toilet Trained?
Languages Spoken
Do Both Parents Live With the Child?
If Not, what is the arrangement?
Agreement:
Rishon Early Childhood Center reserves the right to curtail services due to non-payment or other circumstances determined by Rishon Early Childhood Center after due notification to the parent or legal guardian. Refunds in such an event are at the sole discretion of Rishon Early Childhood Center. Children cannot participate unless all necessary information is submitted. I allow the use of photographs containing my child to be used in the future publicity materials. I understand and authorize Rishon Early Childhood Center to make all necessary decisions in the event of an emergency, when i or the emergency contact person I have listed are not available.
By clicking SUBMIT below you agree to the statement above.
Please fill out the below application, or for your convenience a PDF file is also available to print.
