Miss Melissa’s Modified Montessori Preschool
1904 Resort Street
Baker City, OR 97814
541-519-9729
REGISTRATION INFORMATION
Miss Melissa’s Modified Montessori Preschool
1904 Resort Street
Baker City, OR 97814
541-519-9729
REGISTRATION INFORMATION
Child’s Name__________________________________________________
M___F___ Age _____ Birth Date (M/D/Y) __________________________
Height________inches Weight________lbs Eye Color_____________
Address______________________________ Postal Code ______________
Email address__________________________________________________
Is there a custody agreement? Yes _____ No _____ If yes, please explain:
(Photocopy may be required)
_____________________________________________________________
Medical Information
Medical #___________________________________
Doctor__________________________ Phone________________________
Does your child have any physical, mental, emotional or behavioral disabilities of which staff should be aware of? Please explain.
_____________________________________________________________
____________________________________________________
Medication (name, dosage, side effects)
_____________________________________________________________
Medical Alert Information (allergies, etc.)
_________________________________________________________ Immunizations: photocopy provided ___ Conscientious objector signed ___
Parent Information
Name _____________________________Relationship________________ Home Phone _______________________Cell _______________________
Employer __________________________Phone _____________________
Pick up authorization Yes_____ No _____
Name _____________________________Relationship________________
Home Phone _______________________Cell _______________________
Employer _________________________ Phone _____________________
Pick up authorization Yes_____ No _____
Emergency Contacts (different from above)
Name _____________________________Relationship________________ Home Phone _______________________Cell _______________________
Employer __________________________Phone _____________________
Pick up authorization Yes_____ No _____
Name _____________________________Relationship________________
Home Phone _______________________Cell _______________________
Employer _________________________ Phone _____________________
Pick up authorization Yes_____ No _____
Name _____________________________Relationship________________
Home Phone _______________________Cell _______________________
Employer __________________________Phone _____________________
Pick up authorization Yes_____ No _____
***Please provide a list of any person(s) NOT permitted access to your child. Include first and last name.
____________________________________________________________
Guardian Signature____________________________________ Date___________________________