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Student Enrollment Form

Please complete the student enrollment form below. Note, a separate form will be required for each child enrolled in the program. If you have questions please contact Scarlett Roth.

Student Information

Child's Full Name

Preferred Name

Birthday

Gender

Male

Female

Registration Date

Street Address

City

State

Zip code

Parent / Guardian Information

Parent/Guardian 1

Employer

Relationship to Child

Work Phone

Cell Phone

Parent/Guardian 2

Employer - Parent 2

Email - Parent 2

Relationship - Parent 2

Work Phone - Parent 2

Cell Phone - Parent 2

Emergency Contact

Emergency Contact Name

Cell Phone

Relationship to Child

Work Phone

Release to a Non-Parent

To whom may your child be released to other than a parent? Please list their name(s), relationship and phone numbers.

Release to Non-Parent

Medical, Allergies & Other Information

Please list any other information concerning your child which will be helpful to us:

Physician's Name

Physician's Phone Number

Your signature on this form verifies that the information given is correct and that you give permission to the staff of Merry Hearts to provide the necessary care for your child either on site or at the nearest medical facility in the event of a medical emergency. In the even of such an emergency we will make every effort to reach you or your emergency contact.

Your Signature

Select a date

Thank you for completing the student enrollment form!

The Merry Hearts

Preschool at Bethesda Presbyterian Church

< Back to Forms & Policies

Student Enrollment Form

Student Information

Parent / Guardian Information

Emergency Contact

Release to a Non-Parent

Medical, Allergies & Other Information

< Back to Forms & Policies