Parent's Names______________________________________________________________
Mailing Address_____________________________________________________________
Village, State, Zip Code_______________________________________________________
Home Phone Number_________________________________________________________
Father's Work Phone Number__________________________________________________
Mother's Work Phone Number__________________________________________________
Name and address of person(s) having legal custody of child, if other than parents.
Their Name_________________________________________________________________
Their Address_______________________________________________________________
Their Phone Number__________________________________________________________
Name of person to contact if parents cannot be reached______________________________
Their Address_______________________________________________________________
Their Phone Number__________________________________________________________
Doctor's Name______________________________________________________________
Doctor's Address___________________________________________________________
Doctor's Phone Number_______________________________________________________

Are there any medical conditions that I or Mrs Lake (the high school nurse) should be aware of? We need to know about allergies, illnesses, medications, etc.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Who will be responsible for picking up the child?
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________

My students and I will be working with the preschooler to help them learn their full name, phone number, address, and their parent's names. We do not want to confuse them with what you have already begun to teach. Will you please provide us with the following information?
Child's Name________________________________________________________________
Street Address______________________________________________________________
Village and Zip Code________________________________________________________
Phone Number_______________________________________________________________
Birthdate___________________________________________________________________
Child's Gender______________________________________________________________

Comments and or Concerns:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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