NORTHPORT BAPTIST DAY SCHOOL	                    OFFICE USE ONLY   
1004 Main Avenue			   Date child enrolled:________________
Northport, AL 35476		   Date reg. paid:____________________
Enrollment Form 			   Imm. exp. date:___________________
2024-2025 SCHOOL YEAR 	   Allergies:________________________
					   Other:__________________________				
GENERAL INFORMATION
Child's Name:_________________________________________________________________M  F  Name used at home:
Child's Date of Birth: 				  Child's Age on 9-1-24:
Father's Name:				  Employer:			      Work Phone:
Mother’s Name:                                                Employer:                                   Work Phone:                    
Address:		
		       Street			     City and State                                        	       Zip
Home Phone:_______________ Father’s cell:__________________  Mother’s cell:________________
Email address:________________________________________________________________________
Name and ages of siblings:______________________________________________________________
How did you hear about our school?______________________________________________________
EMERGENCY INFORMATION       
Child's Physician:					                                  Phone:
Do we have permission to call your physician in case of emergency?          Yes    No
Persons authorized to act for parents in case of emergency:
1. Name						Phone:			         Work Phone:
2. Name						Phone:			         Work Phone:

CHILD'S MEDICAL HISTORY:          List child's allergies, if any __________________________
If your child has a life-threatening allergy you will need to fill out additional information for our records.
Do you have an immunization form (blue form) for your child?  Yes   No
**Please turn in a copy with registration form**
Has your child had….	
1. Evidence of hearing loss	Yes   No		2. Speech difficulties	Yes   No
3. Vision difficulties		Yes   No		4. Hospitalizations	Yes   No
Other illnesses?  Please list:_____________________________________________________________
Is your child currently or has been before, enrolled in any kid of early intervention?   Yes   No
If so, what kind and where? _____________________________________________________________

TWO’S, THREE’S AND FOUR’S CLASSES (STRUCTURED CLASSES)  	
Two Day (T/Th.)	            	Three Day (M/W/F)			Five Day (M/T/W/Th./F)
Two Year Old   		 	Two Year Old			Two Year Old
Three Year Old			Three Year Old			Three Year Old
										Four Year Old

ONE’S CLASSES (MMO CLASSES)- must be walking AND at least one year of age______________________
One-Day (Wednesday only)  					Two-Day (Tues./Thurs.) 		
Three-Day (Tuesday, Wednesday, and Thursday) 
BABIES CLASS (MMO CLASSES)- must be 3 months-11 months
Two-Day (Tues./Thurs.)  

Social and Physical Growth
Is your child:
 right-handed	 excitable
 left-handed	 restless
 works well with hands/fine motor	 shy
 well-coordinated	 domineering
 happy	 impulsive

Does your child:
 have falling spells	 have unusual fears
 have daredevil behavior	 talk well

List methods of discipline used with your child at home:

In what ways do you expect our program to help your child?

Does your child have any problems that concern you at this time?

What is your child’s attitude toward himself/herself?

What do you feel his/her special abilities are?

Experiences with others
What are some of the ways your child plays at home?

Favorite Toys:
Special Interests:
Favorite T.V. Programs:
Does he/she play well with other children?

How does your child react when he/she does not get his way?

Is he/she enrolled in a special group (dancing, art, sports, etc.)?

RELIGIOUS AFFILIATION
Church you attend or denominational preference:
Additional Comments:

Parent or Guardian Signature:						Date: