BOONEVILLE CHURCH OF CHRIST PRE-SCHOOL ENROLLMENT FORM

BOONEVILLE
CHURCH OF CHRIST PRE-SCHOOL
501 N. FIRST STREET - - 728-5547

CHILD ENROLLMENT FORM

Parents, to protect and promote the health and safety of your child please
supply a response to every item on this form. This information is required
by the Mississippi State Department of Health, Child Care Licensure Branch.
If the item is not applicable, please answer ""

Today's Date September 5, 2010

CHILD #1

Last Name:
First Name:

Address Street
City, State
Zip Code

Parent's Names: Mother
Father

Mother's phone numbers: Home
Work
Cell

Father's phone numbers: Home
Work
Cell

Mother's place of employment:
Business Name
Address
Phone

Father's place of employment:
Business Name
Address
Phone

CHILD #2

THE INFORMATION BELOW IS APPLICABLE TO
ALL CHILDREN LISTED ON THIS APPLICATION

In case of emergency and the parents cannot be reached, please contact the following:
(two individuals other than the parents)

Name:	Name:
Phone:	Phone:

The following individuals will be allowed to pick up and drop off my child:

1. Full Name:

2. Full Name:

3. Full Name:

Your Email Address:

Does your child (children) have any allergies?
(must have a doctor's statement to verify for each child)

List any special needs of the above child (children)

My child (children) may be photographed, video taped and
released to the News media
YES NO

My child (children) may take approved field trips sponsored
by Booneville church of Christ PRE-SCHOOL
YES NO

I understand that Booneville church of Christ PRE-SCHOOL
does NOT give medications of any kind without a medication consent form
YES NO

Booneville church of Christ PRE-SCHOOL may give my
child (children) emergency medical treatment if needed
YES NO

I have been given and have read a copy of
MSDH Regulation Summary for Parents
YES NO

A 121 Immunization Compliance Form is on file in this
facility before my child (children) may attend
YES NO

Your request will be sent via e-mail directly to the Pre-School Director