Registration Form

Panther Preschool Registration

Central York High School

(sessions subject to change)

Please check preferred session.

_________ Multi-Age (T/TH)

__________ 4 year olds (M/W/F)

Date received __________ (office use)

Child's Name________________________________________________________________________
(Last) (First) (Middle) (Nickname)

Child's Birthdate_________________________ Current Age ___________ Gender __________ Month/ Day/ Year

Parent/Guardian Names_______________________________________________________________

Elementary School child will be attending (if known)________________________________________

Address: (Please include street name)

___________________________________________________________________________________

E-mail Address_______________________________________________________________________

Telephone Numbers :

Home ___________________________ Cell_______________________________________________

Other_______________________________________________________________________________

Other Persons at Home Age Relationship

______________________________________ __________ _________________________

______________________________________ __________ _______________________ __

______________________________________ __________ _________________________

Languages Spoken at Home ___________________________________________________________

List any health concerns _______________________________________________________________

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