Registration

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120 Werthan Circle • Franklin, TN 37064 • 615-791-9003 • E-mail • Jobs • Home Page

PB&J Day School Registration Form



Today's date:
Registering for:	Current school year Fall 2010 school year

CHILD'S INFORMATION

Today's date:
Legal name: (first, middle, last)
Preferred first name:
Gender:	Male Female
Date of birth (month, day, year):
Child's Soc. Sec. Number:

PARENTS' INFORMATION

Father's name:
Address:
City:
State:
ZIP:
Home phone:
E-mail:
Occupation:
Employer:
Business address:
Business phone:
Business e-mail:
	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mother's name:
Address:
City:
State:
ZIP:
Home phone:
E-mail:
Occupation:
Employer:
Business address:
Business phone:
Business e-mail:

PROGRAM CHOICES	(Note: Children should be 1 year old by August 15)

Year your child will enter kindergarten:
	I'd like to enroll my child in the program(s) below. School Sessions: 5 Days (Monday through Friday, 9:00am-3:00pm) 3 Days (Monday-Wednesday-Friday, 9:00am-3:00pm) 2 Days (Tuesday-Thursday, 9:00am-3:00pm) Before/After-Care: Before-Care (8:00am-9:00am) After-Care (3:00pm-4:00pm) After-Care (4:00pm-5:00pm) Enrichment (3:00pm-4:00pm) - check desired class: Art Music Taekwondo Rocket Reading Science Spanish Math Design and Build Cooking

FAMILY INFORMATION

Child's siblings:	Name: Age:
	Name: Age:
	Name: Age:

With whom does the child reside?

Legal guardian’s name and address, if applicable

Language spoken in the home:	English Other (please specify below)

PARENT STATEMENTS

	Please help us know your child by providing the following information. It is understood that young children continue to grow and develop; your responses should describe current circumstances.
	Personal Development:
Yes No	Has your child attended preschool/childcare before?
If yes, school name:
Yes No	Can your child feed her/himself using a spoon and/or fork?
Yes No	Wash and dry her/his own hands?
Yes No	Dress her/ himself with little assistance?
Yes No	Speak so that he/she can be understood by others?
Yes No	Express her/his thoughts and needs easily?
Yes No	Is your child toilet-trained during the day?

	Health History:
Yes No	Has your child ever had trouble seeing?
Yes No	Has your child had frequent ear infections?
Yes No	Does your child have allergies?
Yes No	Has your child had any significant injuries or hospitalizations?
Yes No	Is your child presently on any medications?

	If you responded "yes" to any of the above, please explain. Also, describe any other health concerns.


	Interests/Activities:
Yes No	Does your child play with blocks and construction toys without help?
Yes No	Use crayons or markers to draw?
Yes No	Listen to stories being read out loud?
Yes No	Turn pages of a book and look at pictures?
Yes No	Recall stories and events?
Yes No	Enjoy playing alone or with imaginary friends?
Yes No	Follow simple, age-appropriate directions?
Yes No	Talk with your friends and relatives who come to visit?

	Please describe your child's favorite activities when playing with other children:

	Please describe your child's favorite activities when playing alone:

	Please describe your child's favorite activities when at home with Mom or Dad:

	Please share anything else we should know:


DECLARATION

	By checking the box below, I am stating that the information provided here is truthful and accurate to the best of my knowledge. It is further understood that any misstatement or omission may result in denial of admission or enrollment. I agree. (To complete your application, click on the button below.)