Preschool Child Enrollment Form

Step 1 of 6

To begin, register for Preschool by either calling our office: 712-258-5137 or by filling out this form. Please note, in addition to this online form, several other paper documents are required and can be submitted at the end of this form.

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Child's Address(Required)

Street Address Address Line 2 City State ZIP Code

Food - Can you child eat pork?(Required)

Yes

Allergies, special instructions, comforting items:

Parent/Guardian Information #1

Name of Parent/Guardian #1(Required)

First Last

Relationship to Child:(Required)

Address (if different than child)

Street Address Address Line 2 City State ZIP Code

Home Phone Number

Cell Phone Number(Required)

Email Address(Required)

Work Email Address

Place of Work #1

Work Address #1

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information #2

Name of Parent/Guardian #2

First Last

Relationship to Child:

Address #2 (if different than child)

Street Address Address Line 2 City State ZIP Code

Home Phone Number #2

Cell Phone Number #2(Required)

Email Address #2(Required)

Work Email Address #2

Place of Work #2

Work Address #2

Street Address Address Line 2 City State ZIP Code

Emergency Contacts

Emergency Contact #1(Required)

First Last

Relationship to Child #1(Required)

Emergency Contact Address #1(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number #1

Cell Phone Number #1(Required)

Work Phone Number #1

Email Address #1

Work Email Address #1

Emergency Contact #2

First Last

Relationship to Child #2

Emergency Contact Address #2

Street Address Address Line 2 City State ZIP Code

Home Phone Number #2

Cell Phone Number #2

Work Phone Number #2

Personal Email Address #2

Work Email Address #2

Emergency Contact Name #3 (Out of Area/Out of State)

First Last

Relationship to Child #3

Emergency Contact Address #3

Street Address Address Line 2 City State ZIP Code

Home Phone Number #3

Cell Phone Number #3

Work Phone Number #3

Personal Email Address #3

Work Email Address #3

Medical Information

Child's Doctor's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Preferred Hospital to Contact(Required)

Doctor's Phone Number(Required)

Preferred Hospital Address

Street Address Address Line 2 City State ZIP Code

Hospital Phone Number(Required)

Child's Dentist's Name

First Last

Dentist's Address

Street Address Address Line 2 City State ZIP Code

Dentist's Phone Number

Does your child have any special needs that we need to be made aware of?

Yes

If yes, please describe here.

Persons allowed to pick up child if I am unable to

Also list emergency contacts below if you want to allow them to pick up your child.

Pick Up Person #1(Required)

First Last

Relationship to child #1(Required)

Phone Number #1(Required)

Pick Up Person #2(Required)

First Last

Relationship to child #2(Required)

Phone Number #2(Required)

Pick Up Person #3(Required)

First Last

Relationship to child #3(Required)

Phone Number #3(Required)

Pick Up Person #4

First Last

Relationship to child #4

Phone Number #4

Pick Up Person #5

First Last

Relationship to child #5

Phone Number #5

Pick Up Person #6

First Last

Relationship to child #6

Phone Number #6

Is anyone NOT allowed to pick up your child? (with copy of court order, if applicable.)(Required)

Yes

Please submit documentation when you submit your online enrollment form.

If yes, please list their first and last names

Court Documentation

Drop files here or

Accepted file types: jpg, gif, png, pdf, word, Max. file size: 10 MB.

Please attach Court Documentation is anyone IS NOT allowed to pick up your children from Mary J. Treglia Community House preschool.

Additional Enrollment Forms (upload here) *These forms are located on our website here: https://www.marytreglia.org/program-forms. To view the webpage, please copy and paste the above URL in a new browser window so you don't lose your progress on this application.

Drop files here or

Accepted file types: jpg, pdf, doc, docx, Max. file size: 10 MB, Max. files: 10.

Please make sure to attach the following forms:* Health, Health Status, Emergency Medical Treatment Authorization, Iowa Eligibility Application, Student Registration, I-Smile Oral Health Program, Iowa Child and Adult Care Food Program and Iowa KidSight Consent forms.