Berean Education Center Enrollment Form Berean Education Center – Phone 952-223-1814 DATE______________ Child’s name_____________________________________________________________Sex____ (last) (first) (middle) Home address__________________________________City________________________Zip________
E-mail address: _________________________________________________________ Telephone ______________________Date of birth _________________Place of birth______________ (area code) I give my permission to have our names, address, & phone number, printed on a class list. Yes _________ No _________ Do we have permission to share your name/number for carpool reasons for Pre-School, Pre-K, and Kindergarten only. Yes___________ No__________ Mark the class in which your child is enrolled: 3's Mon/Wed AM ____ Tues/Thurs. AM ___ 4'S Mon/Wed/Fri AM ____ Mon/Wed/Fri PM____ 4’s Tues/Thurs AM ___ PM ____ Pre-Kindergarten PM _____
Preschool Plus M - F (6:30 AM - 6 PM) _____________ Days Attending School Age M - F (6:30 AM - 6 PM) ______________ Days Attending
Father's name__________________
Mother's name_______________________
Address ____________________
Address _________________________
Occupation_____________________ Employer________________________ Business phone__________________
Occupation___________________________ Employer_____________________________ Business phone_______________________
Marital status: married and living together_______ Separated ________divorced ______ spouse deceased______ Is applicant of present marriage _________adopted ________custody _______ Children living with your family (Give name and age): _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________________________________
Others living in the home________________________________________________________ Name of the school district in which you reside_______________________________________ How did you hear about BEC? Friend ______ Telephone Book ________ Drove by _____ Child Care Resource & Referral ____________ Church ______ Local newspaper _____
This next section must have all the blanks filled in, to be complete Name and phone number of person(s) who may pick up your child. (carpool parents and phone number must be on file) Name ________________________________ Phone _______________ Relationship ______________ (area code)
Name ________________________________ Phone _______________ Relationship ______________ (area code)
Is there anyone who MAY NOT pick up your child? Yes ______ No _______ Give name of person(s) who MAY NOT pick up your child ______________________________ Family Physician _____________________ Address _______________________ Phone ___________ (area code)
Family Dentist _______________________ Address _______________________ Phone ___________ (area code)
IN CASE OF EMERGENCY CONTACT: Family Physician _____________________ Address _______________________ Phone ___________ (area code)
Family Dentist _______________________ Address _______________________ Phone ___________ (area code)
Hospital ____________________________ Address _______________________ Phone ____________ (area code)
Name of persons who may pick up your child, if you cannot be reached: (local phone #’s only and phone #’s we can reach during school hours). Name ________________________ Address _______________________ Phone ___________ (area code)
Name ________________________ Address _______________________ Phone ___________ (area code)
Berean Education Center has my permission to secure medical help including the services of the rescue squad or the Emergency Room of Fairview Ridges Hospital in the event of an emergency. _____________________________________________________________________ _____________________________ Signature
Date
Special Medical Information: Dietary _____________________________________________________________________ Asthma _____________________________________________________________________ Allergies ____________________________________________________________________ Other __________________________________________________________________