Please fill out the form in it entirety. If any particulare section does not apply, please notate "no" or "none". Thank you.
  • MM slash DD slash YYYY
  • Childs Information

  • MM slash DD slash YYYY
  • (For internal correspondence only)
  • (if any)
  • Parent Information - Mother / Guardian

  • Parent Information - Father / Guardian

  • Family Information

  • Health Information

  • Physician Information

  • Emergency Contact

    Person(s), other than a parent, whom you authorize West Haven Preschool to contact for guidance in a medical or other emergency situation if the child's parents/guardians can not be reached.
  • NameRelationship to ChildPhone Number 
    At least one person required.
  • Release Authorization

    Please list the persons other than the parent/guardian which West Haven is authorized to release your child to. West Haven Preschool will not release your child to anyone that is not identified below. The parent/guardian agrees that he/she will ensure that all authorized pick up persons are aware that your child must be escorted to and from the classroom, and signed in and out of the classroom. West Haven will not allow any child to enter or leave without an escort. The complete address for each individual must be provided.
  • NameRelationship to ChildAddressPhone 
  • This field is for validation purposes and should be left unchanged.