HomeFamily Studies and Human DevelopmentWaitlist Preschool Waitlist Form Preschool Waitlist - active version Child's Information First Name * Last Name * Gener * Male Female Date of Birth Does your child have food, insect, pet allergies or asthma? Yes No Please describe them below. * What first name would you like your child to learn to print? * List information which we should have concerning your child which would help us to understand him/her better. * List older and/or younger siblings and ages. * Enter "none" if your child has no siblings. Primary Caregiver Information Please enter the information for the parent or guardian who should be our primary contact. Relationship to child: * MotherFatherStep-motherStep-fatherGrandmotherGrandfatherAuntUncleSiblingOther Relationship to child: First Name * Last Name * Email Address Preferred Phone * Home Phone Cell Phone Home Phone * Cell Phone * Permanent Address * Permanent Address Permanent Address Permanent Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Secondary Caregiver Information If the child has a second parent/guardian who we may contact, please enter their information below. If you choose not to add a second parent or guard, please leave "Relationship to child" as "none". Relationship to child: * NoneMotherFatherStep-motherStep-fatherGrandmotherGrandfatherAuntUncleSiblingOther Relationship to child: First Name * Last Name * Email Address Preferred Phone * Home Phone Cell Phone Home Phone * Cell Phone * Use same address as Primary Caregiver? Yes, this parent/guardian lives at the same address as the first. No, this parent/guardian has a different home address. Separate Address * Separate Address Separate Address Separate Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Emergency Contact Who should we contact first if your child needs to be picked up early due to illness? Contact's Name * Relationship to Child * MotherFatherGrandparentBrotherSisterAuntUncleLegal GuardianOther Relationship to Child Contact's Email Address Contact's Phone Number * Additional Info Release Form for field trips, college friend days, and media * Field trips - fire station College Friend Day - may be away from the classroom but on campus and are supervised by class instructor and preschool teacher Any and all media i.e. (video tape, audio recording, still pictures) for educational purposes in conjunction with Dixie State University classes I hereby give permission for my child to participate in the activities selected above: Insurance Agreement: Dixie State University can NOT provide health and accident coverage for children under college age. You are urged to provide coverage while your child is in the preschool. I understand the Insurance Agreement * Yes Signature signature keyboard Clear If you are human, leave this field blank. Submit This form is currently closed for submissions.
