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Kinder Klass Application for the
2012-2013 School Year |
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| _______________________________________ Child's Name |
_______________________________________ Nickname |
| _______________________________________ Address |
________________________________________ Home Phone Number |
| ___________________________ Birth Date |
________ Sex |
| _________________________________________ Father's Name |
________________________________________ Business Phone Number |
| _________________________________________ Mother's Name |
________________________________________ Business Phone Number |
| _____________________________________________ Emergency Contact Name and Phone Number |
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_________________________________________________________________________________ Physicians Name, Address and Phone Number: ____________________________________________ |
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| Is your child right or left handed? _______________________________________________________ | |
| Limitations or handicaps ______________________________________________________________ | |
| Allergies __________________________________________________________________________ | |
| Special Interests ____________________________________________________________________ | |
| Siblings names and ages ______________________________________________________________ | |
| Are there any concerns we should be aware of
(recent death, divorce, very activie or quiet, et...?
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| Please number the classes below in order of
preference and we will do our best to honor all requests.
Monday, Wednesday, Friday Pre-K _____ Tuesday -
Thursday A.M. _____
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| Please list the names of people who have
permission to pick up your child and their relationship to the child:
Name: Relationship:
Phone Number: |
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