IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
REGISTRATION FORM
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
PHOTO
REGISTRATION FORM
Childs Information
Childs Name: _____________________________________________________________________________
FIRST
Sex: ____________________
MIDDLE
SURNAME
Birth Date: ____________________
Age: ___________________
Parents Information
Name of Mother/Guardian: __________________________________________________________________
Address: __________________________________________________________________________________
Home Phone #: ______________________________
Mobile#: __________________________________
Place of Employment: _______________________________________________________________________
Job Title: ______________________________
Period of time working there: _________________
If own company, give a brief description of what company is about:
__________________________________________________________________________________________
Work Phone#: ______________________________
Work Hours: _______________________________
Name of Father/Guardian: ___________________________________________________________________
Address: __________________________________________________________________________________
Home Phone#: ______________________________
Mobile#: __________________________________
Place of Employment: _______________________________________________________________________
Job Title: ______________________________
Period of time working there: _________________
If own company, give a brief description of what company is about:
__________________________________________________________________________________________
Work Phone#: ______________________________
Work Hours: _______________________________
__________________________________
____________________________________
MOTHER/GUARDIAN
FATHER/GUARDIAN
__________________________________
____________________________________
DATE
DATE
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
Marital Status of Parents:
( ) Married
( ) Common Law
( ) Separated ( ) Divorced
( ) Other: _________________________
If parents are separated or divorced:
Name of Stepfather: _________________________________________________________________________
Name of Stepmother: _______________________________________________________________________
Custody or visiting arrangements: ______________________________________________________________
__________________________________________________________________________________________
Emergency Information
Person(s) to contact if parents are unavailable:
Name: ______________________________________
Relationship to child: ________________________
Address: ________________________________________________________
Name: ______________________________________
Phone#:_________________
Relationship to child: ________________________
Address: ________________________________________________________
Childs Physician: _____________________________________
Phone#:_________________
Phone#________________________
Address: __________________________________________________________________________________
Hospital Preference: _________________________________________________________________________
In any event that I cannot be reached, I hereby give my permission for my child to receive any necessary
emergency medical care or treatment. I understand that every effort will be made to contact me, my spouse, or
any of the people named above, before such action is taken. I will be responsible for the payment of such care
or treatment.
__________________________________
____________________________________
MOTHER/GUARDIAN
FATHER/GUARDIAN
__________________________________
____________________________________
DATE
DATE
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
Health & Personal Information
Blood Type:
Childs Blood Type: _____________________
Mothers Blood Type: ___________________
Fathers Blood Type: ____________________
Diseases or Medical Conditions:
Asthma
Yes ( )
No ( )
Measles
Yes ( )
No ( )
Scarlet Fever
Yes ( )
No ( )
Whooping Cough
Yes ( )
No ( )
Mumps
Yes ( )
No ( )
Chicken Pox
Yes ( )
No ( )
Poliomyelitis
Yes ( )
No ( )
Epilepsy
Yes ( )
No ( )
Heart Disease
Yes ( )
No ( )
Rheumatic Fever
Yes ( )
No ( )
Kidney Disease
Yes ( )
No ( )
Diabetes Type 1
Yes ( )
No ( )
Diabetes Type 2
Yes ( )
No ( )
Hepatitis
Yes ( )
No ( )
Other (please specify) _______________________________________________________________________
__________________________________
____________________________________
MOTHER/GUARDIAN
FATHER/GUARDIAN
__________________________________
____________________________________
DATE
DATE
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
Is the child highly susceptible to any of the following?
Colds
Yes ( )
No ( )
Tonsillitis
Yes ( )
No ( )
Earaches
Yes ( )
No ( )
Stomach aches
Yes ( )
No ( )
Vomiting
Yes ( )
No ( )
Short breath
Yes ( )
No ( )
High fevers
Yes ( )
No ( )
Has the child had any serious operations or accidents?
Yes ( )
No ( )
Details: ___________________________________________________________________________________
__________________________________________________________________________________________
Does the child have any allergies?
Yes ( )
No ( )
Details: ___________________________________________________________________________________
__________________________________________________________________________________________
Please add any comments that you feel will help us to know your child better.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________
____________________________________
MOTHER/GUARDIAN
FATHER/GUARDIAN
__________________________________
____________________________________
DATE
DATE
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
Pick-Up Permission
I ____________________________, hereby give permission for my child _____________________________,
to leave Im Strong Preschool, with the following person(s) named below. It is my responsibility to notify the
person in charge, in writing, of any changes.
Name of Person: ____________________________________________________________________________
Relationship to child: _____________________
ID#:__________________
Phone #: ________________
Name of Person: ____________________________________________________________________________
Relationship to child: _____________________
ID#:__________________
Phone #: ________________
Name of Person: ____________________________________________________________________________
Relationship to child: _____________________
ID#:__________________
Phone #: ________________
Name of Person: ____________________________________________________________________________
Relationship to child: _____________________
ID#:__________________
Phone #: ________________
If there is a separation divorce custody situation which will determine collection of your child on particular
days, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________
____________________________________
MOTHER/GUARDIAN
FATHER/GUARDIAN
__________________________________
____________________________________
DATE
DATE
Form must be completed and submitted with two (2) passport sized photos and a copy of the childs birth
certificate, immunization record, custody/legal guardianship papers (if applicable).
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
Authorized Use Only
Notes:
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Date application received: _________________________
Date of entrance: ________________________________
Date of withdrawal: ______________________________
Reason for leaving:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________
MS. LUANNA A. ARMSTRONG
Owner/ Principal
IM STRONG PRESCHOOL
LP#3 Edma Avenue, Samaroo Village, Arima
Website: www.imstrong/preschool.edu
Phone: 667-4763
