Kailua Methodist Preschool
1110 Kailua Road Kailua, HI 96734
Phone: 262-7674
Application Form
Today's Date ______________
Child's Name______________________________________________ Sex: M / F Date of Birth: ________________________
Parent/Guardian Name(s)___________________________________________________________________________________
Home address________________________________________________________ City/Zip_______________________________
Home Phone__________________________ E-Mail Address:_______________________________________________________
Mother/Guardian cell_______________________________ Father/Guardian cell______________________________________
Are you a member of Kailua United Methodist Church? Yes / No
Parent/Guardian Employment Information:
Father/Guardian: _________________________________________________________________________________________
(Company Work Name and Address) (Work Phone)
Mother/Guardian: _________________________________________________________________________________________
(Company Work Name and Address) (Work Phone)
Person to contact (other than parents) in case of emergency:
Name______________________________________ Phone: 1)_______________________ 2)___________________________
Name______________________________________ Phone: 1)_______________________ 2)___________________________
List any and all allergies, physical or medical difficulties your child has:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Has your child ever attended another preschool? Yes / No
If yes, Name of Preschool: _________________________________________________ City/State ________________________
How long did they attend? ________________ Reason for withdrawal: _______________________________________________
Schedule preferred: (please mark a 1st and 2nd choice)
M-F (5 days) 8:00-12:30 _____ 7:00-3:30 _____ Start Date: _________________________________
M, W, F (3 days) 8:00-12:30 _____ 7:00-3:30 _____
T, TH (2 days) 8:00-12:30 _____ 7:00-3:30 _____
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Office Use Only
Application Fee ____ Registration Fee ____ Tuition Deposit ____ Annual Comp. Fee ____ Emergency Card ____
Birth Cert. (copy) ____ Hawaii Form 14 ____ TB Record ____ DTaP (4) ____ Hib ____
Polio-IPV (3) ____ Hep B ____ MMR (1) ____ Varicella (1) ____ Form 908________