Register Please fill out the form to the best of your ability. Step 1 of 4 25% Child's InformationChild's Full Name First Middle Last Name Called Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Phone NumberGender Male Female Age as of 09/30/24 Language(s) Spoken in the Home Child Lives With: Mother Father Both Mother and Father Other If other, please specify: Person having legal custody: Family InformationMother's Name First Last Mother's Email Enter Email Confirm Email Mother's Occupation Mother's Business PhoneMother's Cell PhoneFather's Name First Last Father's Email Enter Email Confirm Email Father's Occupation Father's Business PhoneFather's Cell Phone Emergency Contactsother than parentsEmergency Contact 1 Name First Last PhoneRelationship to Child Emergency Contact 2 Name First Last PhoneRelationship to Child Other InformationTo help us get to know your child better.What are your expectations for your child in this class?Please list any fears, habits, or family changes that may affect your child's behavior.Are there any medical or physical issues (including food allergies) so that we can help keep your child safe at school? Yes No If yes, please specify Has your child been screened to receive special services?medical, educational, or therapeutic Yes No If yes, please specify Does your child have now, or previously had, an Individualized Education Plan (IEP)?If yes, please submit a summary of services and status. Yes No Does your family have an Individualized Family Service Plan (IFSP)? Yes No Has your child previously been enrolled in another preschool or day care? Yes No If yes, please list name and location: Are you a member of Huguenot Road Baptist Church? Yes No What is your Church Home? EmailThis field is for validation purposes and should be left unchanged. Δ
