Enrollment Form

1. Our Saviour Lutheran Preschool
120 South Henry Street, Green Bay, Wisconsin 54302
††† Enrollment Information Sheet†††
Child’s Name (first & last) _________________________________ Birthdate ___/___/___ Gender ____
Name your child will be called (ex. Thomas or Tom) __________________________________________
Baptized? ___No ____Yes Date: ___/___/___ Church You Attend ____________________________
Home Address _________________________________________Home Phone ______________________
Parents are: Married ____ Separated ____ Divorced ____ Widowed ____ Other ___________________
Child resides with: Mother ____ Father ____ Both ____ Other ____
Children in Family (name(s) & age) _________________________________________________________
Who is to be notified in an emergency if parent or guardian is not available?
_________________________________________________________________________________
Name Address Telephone Cell Relationship
_________________________________________________________________________________
Name Address Telephone Cell Relationship
Child’s favorite play activities:
________________________________________________________________________________________
Has your child had previous group experience? Y or N Where?____________________________________
Does your child have neighborhood playmates? Y or N Is your child (circle) right-handed or left-handed
Circle the most characteristic behaviors of your child:
calm, excitable, easily angered, whines, crying, happy, cheerful, stubborn, quiet, cooperative,
independent, active, fights often, gives in easily, temper tantrums, wants own way
What behavior do you consider most difficult to deal with ________________________________________
Father’s Name ____________________________
Home Address & Phone (if different from child)
Occupation:_______________________________
Employer: ________________________________
Business Phone: __________________________
Email: __________________________________
Mother’s Name ____________________________
Home Address & Phone (if different from child)
Occupation:_______________________________
Employer: ________________________________
Business Phone: __________________________
Email: __________________________________

2. PERMISSION TO RELEASE INFORMATION
We like to provide our parents with a list that includes all the children in your child’s class. This
information is provided to parents as a helpful tool in arranging play dates and to contact parents for
other needs. We are asking that you give us permission to include your child’s information on that
list.
We also are asking for permission to use your child’s picture in advertisements for the school.
These pictures would be used on slide show presentations, and/or newspapers, highlighting special
school events.
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Child: _____________________________________Class: _____________________
[ ] My child’s name, address and telephone number may be included and released on the class
list provided to parents in my child’s class.
[ ] You may NOT release any information on my child on a class list.
[ ] Yes, you can use my child’s picture in class newsletters that will be posted on our Webpage
under Preschool Information. (By checking this box your child’s pictures will be
included in monthly newsletters.)
Parent: ______________________________________Date: _____________________
(Signature of parent or guardian)
Allergies _____________________________________ Fears ________________________________
Any problems with bladder ________________________Bowel _______________________________
Do you have any concerns about your child’s speech, hearing, vision or other problems/concerns? (Please explain)
Child’s Physician: _______________________________________Telephone: ___________________
Address: ___________________________________________________________________________
I give my permission for emergency medical care or treatment to be used if I cannot be reached at once:
___________________________________________________________________________________
Signature of Parent or Guardian Date