Kailua Methodist Preschool

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 _____

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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________