Preston Academy Preschool Application - Preston Children's Academy

Preschool Application

Fill out this application to apply your child for preschool at Preston Academy.

Child Information
Child's Name
First Middle Last
Child's Date of Birth
Date Format: MM slash DD slash YYYY
Does your child have any allergies?
- Yes
- No
If yes, please explain:
Father/Guardian Information
Father/Guardian's Name
First Last
Father/Guardian's Place of Employement
Father/Guardian's NC Driver's Licence #
Father/Guardian's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Father/ Guardian's Email
Mother/Guardian Information
Mother/Guardian's Name
First Last
Mother/Guardian's Place of Employment
Mother/Guardian's NC Driver's Licence #
Mother/Guardian's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother/Guardian's Email
Emergency Care Information
Name of child's doctor
First Last
Doctor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor's Office Phone
Name of child's dentist
First Last
Dentist's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dentist Office Phone
Hospital Preference
Insurance Carrier
Insurance Policy Number

Emergency Contacts (Not Parents)

Name	Relationship	Phone

If a parent cannot be contacted, the following person(s) may be contacted in the event of an emergency. The following person(s) also have permission to pick up.

Required Signatures
I have agreed to submit this application by electronic means. By signing this application electronically, I certify that my answers are correct and complete to the best of my knowledge. I understand that an electronic signature has the same legal effect and can be enforced as the same way as a written signature.
Step 1. Check the box below*
- By checking this box and typing my name below, I am electronically signing my application
Step 2: Type in your name*
First Middle Last Suffix

Preschool Application

Child Information

Father/Guardian Information

Mother/Guardian Information

Emergency Care Information

Required Signatures