DATE ___________________                                         DATE______________

                                                                            (Received at NS Office)

Registration Form – Revised 2/01/08    

St. John’s United Church of Christ Nursery School

1811 LINCOLN WAY EAST - CHAMBERSBURG, PA 17202 (717-264-8224)

Select one:            3y2d___          3y3d___         

                             4y2d___          4y3d___          4y3dx___        4y5d___         

Date of birth___________________  Age as of September 1^st.2008 ______years______months

Child’s Name_________________________________________________________________

                       (First)                   (Middle Initial)           (Last)                       (name used)                    (male)  / (female)

Address____________________________________________________________________

                        Street                                                                                     City and Zip

Telephone Number___________________ Cell Phone if applicable________________________

Father’s Name_______________________________________ Business Phone_____________

Place of Employment and Occupation_______________________________________________

Mother’s Name ______________________________________ Business Phone_____________

                          (First)                  (Last)               (Maiden)

Place of Employment and Occupation_______________________________________________

Brothers and Sisters and their birth dates (use back if necessary)_______________________________

HEALTH: Any Problems/Allergies________________________________________________

                  Physical Problems       ________________________________________________

Local person to be notified in an emergency if parents cannot be reached:

Name_______________________ Relationship ____________Phone #___________________

I give consent for the teacher to secure emergency medical care for my child if required.

Yes___ No___ If yes, (signature)_________________________________________________

Doctor_____________________________________ Phone # _________________________

Babysitter’s name_____________________________________ Phone#__________________

Babysitter’s address  ___________________________________________________________________

Does your child speak and understand English?             Yes___             No___

The following persons have the right to pick my child up from Nursery School:

             Name:                                                        Relationship:

1.                                                                                                                                  1.

2.                                                                                                                                  2.

3.                                                                                                                                  3.