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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*
MM slash DD slash YYYY
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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