LAKEVIEW PRESBYTERIAN WEEKDAY SCHOOL

REGISTRATION FORM

2007-2008 SCHOOL YEAR

Child’s Name ___________________________________  Date of Birth ___________ Sex ________________

                                  (underline name called)

Address ______________________________________________  Zipcode ______  Phone ________________

Mother’s Name _____________________________________________________________________________

     Address _______________________________  Zip ___________  email ____________________________

     Phone (H) ___________________  (W) ____________________  (Other) ___________________________

     Mother’s  Occupation(s) ______________________  Place of Employment __________________________

Father’s Name _____________________________________________________________________________

     Address _______________________________  Zip ___________  email ____________________________

     Phone (H) ___________________  (W) ____________________  (Other) ___________________________

     Father’s  Occupation(s) ______________________  Place of Employment ___________________________

Religious Affiliation _________________________________________________________________________

Names and years that family members  attended LPWS _____________________________________________

__________________________________________________________________________________________

Has your child ever had any serious illness? ______ What? __________________________________________

Is your child healthy now? __________  If not, please explain ________________________________________

Any Allergies? _____________________________________________________________________________

IN CASE OF EMERGENCY, IF PARENTS CANNOT BE REACHED, CALL:

1. _____________________________________ Relationship _______________ Phone_______________

1. _____________________________________ Relationship _______________ Phone_______________

Child’s Doctor _____________________________________________ Phone __________________________

I hereby authorize Lakeview Presbyterian Weekday School to secure emergency medical care for my child in case of inability to reach me.

Signature _________________________________________________  Date ___________________________

How did you find out about Lakeview Presbyterian Weekday School?  _________________________________