Registration Form

* = Required Fields

Child Information

Child's Full Name*
Name Child Goes By*
Date of Birth*
Sex*MaleFemale
Child's Primary Language*
Other Languages Spoken At Home*
Major Medical Concerns/Allergies*
Home Address*
Which class are you registering for:*---2 day Preschool Ages 3/43 day Morning Pre-K Ages 4/55 day Morning Pre-K Ages 4/5+

I confirm my child is an independent toilet user*

Parent or Guardian Information

We require a minimum of two emergency contacts.

Primary Contact

Name*
Relation to child:*---FatherMotherGuardian

Address*Same as ChildNew Address

Email*
Cell Phone
Work Phone
Occupation and place of employment

Secondary Contact

Name*
Relation to child:*---FatherMotherGuardian

Address*Same as ChildNew Address

Email*
Cell Phone
Work Phone
Occupation and place of employment

Releases

Emergency Procedures*: I authorize NHCA to contact emergency care for my child and authorize any medical professional to take the necessary measures for my child's life in case of life threatening situations. I understand that I will be contacted as soon as possible.
Confidentiality*: I give permission to NHCA to release information from my child's file to the emergency care personnel. I give permission for information to be given to the administration of NHCA from my child's physician or other professional sources in the even of an emergency transfer.
Photo Release: My permission is given for photographs and video to be taken of my child during preschool activities. These images may be used in our preschool's promotional video and/or end of year yearbook/slideshows and other promotional purposes. Some class projects may require photos as well.

Please note that clicking submit will act as an electronic signature for the purposes of this form.