Clemmons First Baptist Church
Reaching Our Changing World for Christ
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CLEMMONS FIRST BAPTIST PRESCHOOL
PO Box 279
CLEMMONS, NC 27012
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Indicates required field
Child's Name (Last, First, Name Used)
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Sex
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Male
Female
Date of Birth
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Age
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Parents'/Guardians' Names
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Street Address
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City, State, Zip Code
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Home Phone #
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Cell Phone #
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E-mail address
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Food Allergies?
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Numbers and names to call if your child becomes sick or in case of emergency during Preschool hours.
1. Phone #, Name and Relationship
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2. Phone #, Name and Relationship
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3. Phone #, Name and Relationship
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Doctors: Name / Phone
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In the event that my child has a medical emergency and the staff is not able to reach any of my emergency contacts, I give permission to the staff of Clemmons First Baptist Church Preschool to treat my child. If 911 is called and hospital treatment is necessary, I want my child transported to:
Name of Hospital
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Name of Hospital
Insurance Name and #
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Signature of parent/guardian
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Date
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