H4K Registration East

Primary Information

Name of Child Registering*

First Last

Child's Birthday*

Age on September

Address*

Street Address Address Line 2 City State ZIP Code

Father's First and Last Name*

First Last

Home Phone

Father's Cell Phone

Father's Address*

Street Address Address Line 2 City State ZIP Code

If same as Child's just type the word same.

Father's Occupation and Employer

Father's Work Phone

Father's Email

Mother's First and Last Name*

First Last

Mother's Cell Phone

Mother's Email

Mother's Address*

Street Address Address Line 2 City State ZIP Code

Mother's Occupation and Employer

Mother's Work Phone Number

Parent(s) marital status*

Parent(s)/Guardian(s) with legal custody:*

Name of Adult (Besides Parent) Authorized to pick up your child*

First Last

Adult's Relationship to Child*

Medical Information

Child's Primary Physician

First Last

Physician's Phone

Are your Child's immunizations current?*

Yes
No

List any medications your Child is taking (If none put NA)

Any medical conditions that we need to be aware of? (If none put NA)

Child's Allergies (If None put NA)*

Name of Emergency Contact Nos*

Add more if you have

Other Information

Elementary School your child will be attending

Child's Nickname

Your Child is

Right Handed
Left Handed

Name(s) and Age(s) of other children living at home (If none put NA) *

Name	Gender	Age

Does your child need help?*

Dressing
Undressing
Tying Shoes
Washing Hands
Eating
None

How long has your child been potty trained?

What expression is used when he/she needs to use the restroom?

Any present concerns about your child's behavior?

Have any other individuals cared for your child?

Yes
No

If so by whom?

If so by whom? (If none put NA)

How is your child disciplined at home?

Does your child have any particular fears? (If none put NA)*

Does your child have pets? If so list: (If none put NA)

Does your child have experience interacting with other children?

Does your Child play with other or alone?

Alone
With Others

What are your hopes and goals for your child's preschool experience?

Are there any family circumstances that you think we should be aware of? (If none put NA)

Fall-Spring Registration Options

PRE-K Registration

Early Age H4K

18 months to 3 years

3&4 Year Old Pre-School Registration

Early Drop Off Options

Early Drop Off Costs are in addition to the Registration Cost.

Total Amount

After clicking on 'submit', if your page is not re-directing to payment page, please verify the details again and submit. Once all applicable options have been selected. Please add up your total and click the pay now button to pay your registration cost.