Name of Student ________________________________________________

Student’s Permanent Address ______________________________________

City _____________________  State ___________  Zip Code  ___________

Telephone # _____________________  Date of Birth  _________________

Parent’s Names:

Father  ____________________________   Phone  ______________________

Mother  ___________________________  Phone  _______________________

Mailing address if different from above:

________________________________________________________________

Preschool Background:

List any previous preschool or daycare your child has attended:

School  ________________________________________________  Date Attended  ____________

Reason for change  __________________________________________________________________

School  ________________________________________________  Date Attended  ____________

Reason for change  __________________________________________________________________

Is your child toilet trained? __________________

Does your child need help in:  q Dressing   q Undressing   q Washing hands   q Toilet   q Eating

What is your main reason for sending your child to Lion’s N’ Lambs Preschool/Kindergarten?