GRACE LUTHERAN NURSERY SCHOOL

2191 WEST CHESTER PIKE

BROOMALL, PA 19008

610-356-5423

REGISTRATION APPLICATION

NAME OF PUPIL  ______________________________,  __________________________,  ___________

                           (last)                         (first)            (initial)

      Name child is to be called:  _____________________________________________________

ADDRESS:  ______________________________________________________________________________________

DATE OF BIRTH:  ___________________________   HOME TELEPHONE:  ________________________                        

NAME OF FATHER:  _________________________   NAME OF MOTHER: _________________________

FATHER’S OCCUPATION:  ____________________  MOTHER’S OCCUPATION: ____________________

BUSINESS ADDRESS:  _______________________  BUSINESS ADDRESS:  _______________________

__________________________________________      _________________________________________

BUSINESS PHONE:  ________________________     BUSINESS PHONE:  ________________________

NAME & PHONE NO. OF PERSON (other than parents)  TO NOTIFY IN CASE OF EMERGENCY:

________________________________  _________________  ___________________________________

         (name)                                                       (phone)                             (relation/neighbor)

BROTHERS                                                                    SISTERS

& AGES    __________________________________   & AGES  __________________________________

CHILD’S PHYSICIAN: ____________________________________  PHONE: ________________________

SPECIAL PROBLEMS:     Hearing ______      Speech ______      Allergies _______        Medication _______

                                                               Fears ________          Other _______   (list on back)

NUMBER OF DAYS CHILD WILL ATTEND:  5-AM ____   4-AM ____   3-AM ____   2-AM ____ 

                                                                       5-PM ____   4-PM_____  3-PM_____

ANY PREVIOUS SCHOOL EXPERIENCE?    Yes _____     No _____

RELIGIOUS AFFILIATION:  __________________________________   Baptized?   Yes _____   No ______

REFERRED BY: Friend ____   Newspaper ____   Pediatrician ____   Neighbor ____   Church Member _____

SIGNATURE OF

Parent or Guardian  ______________________________________________________________________

DATE OF APPLICATION:  ______________________________________________