Early Education Program Registration for Little Chargers Preschool

Enrollment Date*

Date

Session*

M/W/TH (4/5 yrs)T/F (3yrs)

Student's Name*

First NameLast Name

Student's preferred nickname

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Date of Birth*

Date

Gender*

MaleFemale

Are you staying in temporary housing?*

YesNo

Are the student's immunizations up to date?*

YesNo

Please upload a copy of the updated immunization record. (Paper copy can also be submitted to the school office)

My child is*

Right HandedLeft Handed

Special needs of the child (allergies, special diet, etc)

Daycare used for after school

Daycare Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Daycare Phone Number

Please enter a valid phone number.

Student's Ethnicity*

Student's Race (choose all that apply)*

Language student first learned to speak*

Language parent uses with student*

Language student uses at home*

Language student uses with friends*

I hereby verify that the above information is true and correct to the best of my knowledge and belief. Signature of Parent/Guardian*

Today's Date*

Date

Mother's Name*

First NameLast Name

Date of Birth*

Date

Email

example@example.com

Highest level of school completed

Mother's Employer/Occupation

Work Phone Number

Please enter a valid phone number.

Father's Name*

First NameLast Name

Date of Birth*

Date

Email

example@example.com

Highest level of school completed

Father's Employer/Occupation

Work Phone Number

Please enter a valid phone number.

Household Yearly Income/before taxes last year, rounding to the nearest thousand.

Please list other children in the family (list names and ages)

The following people have permission to pick up my child from school

Please note: This information is collected according to Minnesota State regulations and will be used for the administration and management of this student's educational program. You are encouraged, but not legally required, to complete all the items on this form.

Birth Certificate: A legal birth certificate or other similar legal identification form must be brought to the school district at the time of registration if entering WWG School District #2898 for the first time.

Immunizations Certificate: Minnesota State Law (Statute 121A.15) requires all children at the time of initial entry to a public school to submit a signed statement from a physician or public immunization clinic stating that the child has been immunized against Diphtheria, Tetanus, Pertussis, Mumps, Rubeola (hard, red) Measles, Rubella (German) Measles, Polio, Varicella, and Hepatitis B. Exemptions to the law are available to anyone who has a medical concern or a conscientious objection to receiving the vaccine. A notarized form must be on file for those choosing exemption.

Child's Social Security Number: The school can make a copy of the Social Security Card for the child's permanent records or provide a form for you to fill out.

Signature of person completing this registration*

Printed Name*

First NameLast Name

Early Education Program Registration for Little Chargers Preschool

Student Information

Student's Language

Parent/Guardian Information

Mother's Information

Father's Information