Falls Church Extended Care Sign-up Form

Email*

Enter Email Confirm Email

Today's Date*

Child's Information

Name*

First Middle Last

Preferred name

DOB*

Gender*

Male
Female

Home Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Previous Child Daycare Programs and Schools Attended:*

Years / Grade(s)*

Allergies, Food intolerance, or Health Concerns*

Epi-pen needed?*

Yes
No

Chronic Physical Problems/Pertinent Developmental Information*

Child's Physician*

Physician's Phone*

Child's Dentist*

Dentist's Phone*

Family Information

Name of Parent/Guardian 1*

Address of Parent/Guardian 1*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Place of Employment*

Work Phone

Name of Parent/Guardian 2

Address of Parent 2

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Place of Employment

Work Phone

Email

Sibling information

Name

Current School

Grade

Name

Current School

Grade

Emergency Contact If Parents Cannot Be Reached

Name 1*

Relationship*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone 1*

Phone 2

Is he/she authorized to pick up the child?*

Yes
No

Name 2

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone 1

Phone 2

Is he/she authorized to pick up the child?

Yes
No

Person(s) Authorized to Pick up Child

Name 1

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name 1

Relationship

Phone 1

Phone 2

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone 1

Phone 2

Person(s) NOT Authorized to Pick-up Child

Un-authorized Person 1

Un-authorized Person 2

Communications

We communicate via e-mail much of the time. Please list any and all address(es) to which you would like Communikids Preschool & Children's Language Center to be delivered:

Email 1*

Email 2

Do you give permission to CommuniKids Preschool to include your contact information in our school directory for release to fellow CommuniKids Preschool parents?

Guardian/Parent 1*

Yes - you may share my phone number
No - do NOT share my phone number
Yes - you may share my email
No - do NOT share my email

Guardian/Parent 2

Yes - you may share my phone number
No - do NOT share my phone number
Yes - you may share my email
No - do NOT share my email

Please initial that all the above information is true:

Parent/Guardian's initials*

Bilingual Preschool, Classes & Camps

Falls Church Extended Care Sign-up Form

Falls Church Extended Care Sign-up Form

Child's Information

Family Information

Sibling information

Emergency Contact If Parents Cannot Be Reached

Person(s) Authorized to Pick up Child

Person(s) NOT Authorized to Pick-up Child

Communications

Do you give permission to CommuniKids Preschool to include your contact information in our school directory for release to fellow CommuniKids Preschool parents?

Please initial that all the above information is true:

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