Registration Information
Child’s Name ________________________ Birthdate __________________________
Address ___________________________ City __________________ Zip _____________
Phone ______________________________ Email________________________________
Father’s Name _________________________ Mother’s Name _______________________
Occupation ____________________________ Occupation _________________________
Employed at ____________________________ Employed at________________________
Phone _______________________________ Phone_____________________________
Siblings: Name _____________________________ Age____________
Name _____________________________ Age ____________
Name _____________________________ Age ____________
Church Attending ____________________________________________
Is your child adopted? _________ At what age? _______ has he/she been told? _______
What are your goals/expectations for your child during this preschool experience?
______________________________________________________________________________
______________________________________________________________________________
Share your child’s strengths and challenges
______________________________________________________________________________
______________________________________________________________________________
Any additional comments or concerns?
______________________________________________________________________________
______________________________________________________________________________
People authorized to take child from Grace Preschool and Early Childhood Center:
Name _____________________________________ Phone _______________________
Name _____________________________________ Phone _______________________
Name _____________________________________ Phone _______________________
Who is NOT ALLOWED to pick up your child? ________________________________
Parent Signature ____________________________________ Date_________________

Permission and Release Form
Child’s Name ___________________________________Date of Birth______________
Parent/Guardian Name(s) ___________________________________________________
Information/Publication Release
I give permission for my child’s name and family contact information (email, phone, address) to be listed in a school directory.
□ Yes
□ No
I give permission for my child’s
Artwork/ Photo/ Writing/ Video image
To be included in:
□ Preschool or GELC publications/advertising
□ GPS/GELC Website
□ GPS Facebook page
Images will be used for education or promotional purposes and children’s full names will not be used.
Field Trips/Walks
I understand that my child will regularly participate in field trips/walks while enrolled in
Grace Preschool. We recognize that unanticipated situations can arise that are not reasonably within the control of the supervising staff. In such an instance, we agree that
Grace Preschool and the supervising staff will not be held legally responsible in the event of an accident or injury.
I have read carefully and understand the above information. I have indicated my consent and authorization
where applicable.
Parent/Guardian Signature: _____________________________Date: _____________

Parent Release
Diapering (Toddlers)
Grace Preschool has my permission to use diapering products, specifically pre-moistened wipes and ointments for rash while my child is in attendance.
Child’s Name_____________________________________________________
Parent/Guardian__________________________________________________
Date____________________________________________________________

Emergency Card
Name__________________________________________Birth date_________________
Parent’s Names___________________________________________________________
Phone (Home) _________________ (Work) ________________ (Mobile) ____________
Alternate Contacts______________________________________Phone______________
______________________________________Phone______________
______________________________________Phone______________
Doctor__________________________Address__________________________________
Dentist__________________________Address_________________________________
Allergies________________________________________________________________
Other Information________________________________________________________
Last DPT Shot (Date) _____________________________________________________
This authorizes the staff of Grace Preschool to give my child emergency medical attention, in case of injury or accident while in attendance on school property. In the event the parents cannot be reached, the child’s personal medical source is unavailable; it is my understanding that staff in charge will call 911.
Parent/Guardian Signature__________________________________________________
Date________________Insurance Company and Phone___________________________
Hospital of Choice if Insurance Stipulated_______________________________________
Doctor Emergency Phone___________________________________________________
Dental Emergency Phone___________________________________________________

Parent Volunteer
(Please indicate areas of interest and availability)
Share your occupation ______
Make Playdough ______
Classroom assistant ______
Repair/Maintenance ______
Maintain Parent Center ______
Play Instrument _______
Prep for Art Activities (cutting, etc…) _______
Maintain Bulletin Board by main entrance ______
Chaperone Field Trips _______
Share Hobby _______
Fundraising Event Volunteer _______
Fundraising Event Organization _______
Lunch Bunch Volunteer ______ (we need 2 volunteers for Mondays and 1 volunteer for Tuesday-Friday)
M _____ T_____ W_____ Th______ F_______
Other Connections _____________________________________________________
Other Suggestions _____________________________________________________
Name___________________________________________Phone__________________
Child’s Name__________________________________
Days available to help: M ____ T ____ W____ Th____ F_____

Health Care Summary
Preschool Enrollment Date__________
Parent/Guardian to complete the following section:
Name of Child____________________________________________________ Birthdate______________
Address________________________________________________________________________________
Parent/Guardian________________________________________Phone____________________________
Name of Physician_______________________________________________________________________
Name of Clinic_________________________________________Phone____________________________
Address________________________________________________________________________________
Healthcare Provider to complete the following section:
Date of last physical exam___________________How long has child been your patient? ________________
Any allergies (include medication, food, environment)? ___________________________________________
Is a modified diet necessary? _______________________________________________________________
Any conditions present that may result in an emergency? _________________________________________
Is the child on any medications? __________If yes, list medications and reason________________________
______________________________________________________________________________________
Vision______________________________ What is the status of the child’s:
Hearing______________________________ Speech_____________________________
Please list below any important health problems, indicate who is following the child for that problem and note any problems that require special attention at the preschool (use back side if needed).
Important Followed Followed by other Requires special
Health Problems by you medical source (name) attention at preschool
_________________
_________________
_________
__________
_______________
_______________
________________
________________
Other information helpful to the preschool____________________________________________________
______________________________________________________________________________________
Signature of healthcare provider and title________________________________________Date___________