WEE SCHOOL

Child's Name *

First Name

Last Name

Sex *

Male

Female

Home Phone *

(###)

###

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Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Name *

First Name

Last Name

Home Address (If different from child's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Number *

(###)

###

####

Cell Number *

(###)

###

####

Work Number *

(###)

###

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Father's Name *

First Name

Last Name

Home Address (If different from child's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Number *

(###)

###

####

Cell Number *

(###)

###

####

Work Number *

(###)

###

####

Emergency Contact 1- Phone Number *

(###)

###

####

Emergency Contact 2- Phone Number *

(###)

###

####

Doctor's Phone Number *

(###)

###

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General Health of Child

Excellent

Good

Fair

Poor

Allergies (If yes, please list below) *

Yes

No

Are All Shots Up to Date? *

Yes

No