IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763

REGISTRATION FORM

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763

PHOTO

REGISTRATION FORM

Childs Information
Childs Name: _____________________________________________________________________________
FIRST
Sex: ____________________

MIDDLE

SURNAME

Birth Date: ____________________

Age: ___________________

Parents Information
Name of Mother/Guardian: __________________________________________________________________
Address: __________________________________________________________________________________
Home Phone #: ______________________________

Mobile#: __________________________________

Place of Employment: _______________________________________________________________________

Job Title: ______________________________

Period of time working there: _________________

If own company, give a brief description of what company is about:

__________________________________________________________________________________________
Work Phone#: ______________________________

Work Hours: _______________________________

Name of Father/Guardian: ___________________________________________________________________

Address: __________________________________________________________________________________
Home Phone#: ______________________________

Mobile#: __________________________________

Place of Employment: _______________________________________________________________________

Job Title: ______________________________

Period of time working there: _________________

If own company, give a brief description of what company is about:

__________________________________________________________________________________________
Work Phone#: ______________________________

Work Hours: _______________________________

__________________________________

____________________________________

MOTHER/GUARDIAN

FATHER/GUARDIAN

__________________________________

____________________________________

DATE

DATE

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763
Marital Status of Parents:
( ) Married

( ) Common Law

( ) Separated ( ) Divorced

( ) Other: _________________________

If parents are separated or divorced:

Name of Stepfather: _________________________________________________________________________
Name of Stepmother: _______________________________________________________________________
Custody or visiting arrangements: ______________________________________________________________
__________________________________________________________________________________________

Emergency Information
Person(s) to contact if parents are unavailable:
Name: ______________________________________

Relationship to child: ________________________

Address: ________________________________________________________

Name: ______________________________________

Phone#:_________________

Relationship to child: ________________________

Address: ________________________________________________________
Childs Physician: _____________________________________

Phone#:_________________

Phone#________________________

Address: __________________________________________________________________________________
Hospital Preference: _________________________________________________________________________

In any event that I cannot be reached, I hereby give my permission for my child to receive any necessary
emergency medical care or treatment. I understand that every effort will be made to contact me, my spouse, or
any of the people named above, before such action is taken. I will be responsible for the payment of such care
or treatment.

__________________________________

____________________________________

MOTHER/GUARDIAN

FATHER/GUARDIAN

__________________________________

____________________________________

DATE

DATE

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763
Health & Personal Information
Blood Type:
Childs Blood Type: _____________________
Mothers Blood Type: ___________________
Fathers Blood Type: ____________________

Diseases or Medical Conditions:

Asthma

Yes ( )

No ( )

Measles

Yes ( )

No ( )

Scarlet Fever

Yes ( )

No ( )

Whooping Cough

Yes ( )

No ( )

Mumps

Yes ( )

No ( )

Chicken Pox

Yes ( )

No ( )

Poliomyelitis

Yes ( )

No ( )

Epilepsy

Yes ( )

No ( )

Heart Disease

Yes ( )

No ( )

Rheumatic Fever

Yes ( )

No ( )

Kidney Disease

Yes ( )

No ( )

Diabetes Type 1

Yes ( )

No ( )

Diabetes Type 2

Yes ( )

No ( )

Hepatitis

Yes ( )

No ( )

Other (please specify) _______________________________________________________________________

__________________________________

____________________________________

MOTHER/GUARDIAN

FATHER/GUARDIAN

__________________________________

____________________________________

DATE

DATE

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763
Is the child highly susceptible to any of the following?
Colds

Yes ( )

No ( )

Tonsillitis

Yes ( )

No ( )

Earaches

Yes ( )

No ( )

Stomach aches

Yes ( )

No ( )

Vomiting

Yes ( )

No ( )

Short breath

Yes ( )

No ( )

High fevers

Yes ( )

No ( )

Has the child had any serious operations or accidents?

Yes ( )

No ( )

Details: ___________________________________________________________________________________
__________________________________________________________________________________________

Does the child have any allergies?

Yes ( )

No ( )

Details: ___________________________________________________________________________________
__________________________________________________________________________________________

Please add any comments that you feel will help us to know your child better.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

__________________________________

____________________________________

MOTHER/GUARDIAN

FATHER/GUARDIAN

__________________________________

____________________________________

DATE

DATE

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763
Pick-Up Permission
I ____________________________, hereby give permission for my child _____________________________,
to leave Im Strong Preschool, with the following person(s) named below. It is my responsibility to notify the
person in charge, in writing, of any changes.

Name of Person: ____________________________________________________________________________

Relationship to child: _____________________

ID#:__________________

Phone #: ________________

Name of Person: ____________________________________________________________________________

Relationship to child: _____________________

ID#:__________________

Phone #: ________________

Name of Person: ____________________________________________________________________________

Relationship to child: _____________________

ID#:__________________

Phone #: ________________

Name of Person: ____________________________________________________________________________

Relationship to child: _____________________

ID#:__________________

Phone #: ________________

If there is a separation divorce custody situation which will determine collection of your child on particular
days, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________

__________________________________

____________________________________

MOTHER/GUARDIAN

FATHER/GUARDIAN

__________________________________

____________________________________

DATE

DATE

Form must be completed and submitted with two (2) passport sized photos and a copy of the childs birth
certificate, immunization record, custody/legal guardianship papers (if applicable).

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763
Authorized Use Only

Notes:
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Date application received: _________________________

Date of entrance: ________________________________

Date of withdrawal: ______________________________

Reason for leaving:
__________________________________________________________________________________________
__________________________________________________________________________________________

__________________________________
MS. LUANNA A. ARMSTRONG
Owner/ Principal

IM STRONG PRESCHOOL

LP#3 Edma Avenue, Samaroo Village, Arima

Website: www.imstrong/preschool.edu
Phone: 667-4763