Registration Form

Student Information

Student First Name *

Student Last Name *

Student Gender *

Student Birth Date *

Allergies *

Food Restrictions *

Email address *

Special Needs *

Medications *

Disabilities *

Special Needs *

Are you comfortable with pictures / videos of your child being shown on my social media pages? *

Yes
No

Contact #1 - Name *

Cell Number *

Email *

Contact #2 - Name *

Cell Number *

Email *

Emergency Contact - Name (a different individual than Contact #1 & Contact #2) *

Cell Number *

Email *

Address *

How did you hear about Little Amigos Preschool? *

Referral Name *

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