kiki@kikistutorpalace.com
(954) 934-2373

 
Application Form    
 
Child's name:
  Last First Middle
 

Enrollment Date:

Sex: 

Date of Birth: 

 
Address:
City State Zip
 

Mother's name:

Mother's cell #

Mother's work #

 
 

Father's name:

Father's cell #

Father's work #

 
 

Guardian name:

Guardian cell #

Guardian work #

 
 
Child Lives With:
Both Parents
Mother
Father
Guardian
 
Allergies
 
Persons Permitted to Remove Child Preschool Facility:
Mother:

Yes

No

Father:

Yes

No

Guardian:

Yes

No

 
Who is authorized to peck up your child?

Relationship to child

Relationship to child

Relationship to child

Relationship to child

 
 
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