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4-5 Yr Old Registration

4-5 Year OId Class Registration
  • Student's Basic Information
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  • First Name*
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  • Last Name*
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  • Age*
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  • Birthdate*
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  • Home Address
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  • Street*
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  • City*
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  • State*
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  • Zip*
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  • Guardian Information
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  • Guardian's Name*Full Name
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  • Emergency Phone*For emergency contact only.
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  • Guardian Email **a valid email address
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  • Secondary Contact
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  • Secondary Emergency Contact Name*
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  • Emergency Phone*
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  • Child Health Information
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  • Child's Immunizations up to date?*
    Yes
    No
    Other
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  • Does child have any known health problems?*
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  • Food*you like
    Asthma
    Eczema
    Croup
    Diphtheria
    Tonsillitis
    Earaches
    Mumps
    Pneumonia
    Polio
    Convulsions
    Measles
    Whooping Cough
    Chicken Pox
    Influenza
    Bronchitis
    Frequent Colds
    Rheumatic Fever
    Other
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  • Please List any major Injuries your child has had?*
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  • Do you have any concerns about your childӳ development?*
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  • Please comment on any other medical information/ or special needs or behaviors I should be made aware of:*
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  • Does your child have any allergies?*
    Yes
    No
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  • Other Information
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  • Are there any holidays you do not want to participate in?*
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  • What are your expectations from Preschool this year?*
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  • Does your child know the alphabet? **0= Not Yet 10= All letters and Sounds
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  • Does your child Know how to read?*0 = Not Yet 10 = Read Simple Words
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  • Conditions and Terms
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  • I agree that if I withdraw my child from Smart Cookie Academy through any part of the school year, I will give 60 days notice before withdrawal and pay for the services my child has received. **
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  • I understand the Application fee is non-refundable **be frank!
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  • This form is legally binding, if you agree, you certify that all of the information provided herein is correct. Providing false information could result in termination of preschool services. You also agree to notify Smart Cookie Academy of any changes to any part of the information provided above. **
    Yes, I agree.
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