Page Title

                                                The Starting Line Preschool
                          Enrollment Application & Agreement

Student Information:

Student Name ___________________________________________ Age ____________ Birthday _____________

Class they will attend:      ____ 2’s          _____3’s         _____4’s

Student’s brother(s) and sister(s): Name ________________________ Age ____________
                                                       Name ________________________ Age ____________
                                                       Name ________________________ Age ____________
                                                       Name ________________________ Age ____________
Parent Information:

Mother’s Name _________________________________ Father’s Name _________________________________

Home Address _______________________________________________________________________________

                                       City _____________________________________   Zip ___________________________

Home Phone _______________________________   Cell Phone _______________________________________

Father’s Employment ________________________________________ Wk Phone _________________________

Mother’s Employment ________________________________________ Wk Phone _________________________

Email Address: _______________________________________________________________________________

ANY MEDICAL CONDITIONS WE SHOULD KNOW ABOUT. (FOOD ALLERGIES, ETC.):

____________________________________________________________________________________________

IN CASE OF AN EMERGENCY, OTHER THAN PARENTS WHOM MAY WE CONTACT?

Name _____________________________________________________   Phone ___________________________

RELEASE: All precautions will be taken to prevent accidents while your child is in class. Simple first aid will be
administered to all minor injuries; parents or doctors will be notified when necessary. I hereby consent to have my child
participate in programs offered by the Starting Line Preschool and their employee’s. It is hereby agreed that I, my child, my
heirs and executors, waive and release all rights and claims for damages that I may have at any time against the Starting
Line Preschool, their employee’s, and its representatives, whether paid or volunteer, for any injury or damages in
connection with the Starting Line program. The risks involved in respect to such a program are fully understood.

SIGNATURE (Parent or Guardian) ______________________________________________ Date _________________

Registration Form

Print page and send in with Registration Fee to:
Starting Line Preschool Attn: Diane Atkins
575 W. Carmel Drive Carmel, IN 46032

Yearly Family Registration Fee $37
Due to reserve your child's spot in
class and is non-refundable.