Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have any of the following? *

Speech difficulty

Nervous habits

Hearing issues

Temper tantrums

Visual problems

Disturbed sleep

None

Christian emphasis is an important part of total education. *

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Church of the Savior Nursery school admits students of any race, color, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies and athletic and other school administered programs. Our National Church body requests certain statistics on enrollments. Please assist us by checking the appropriate one. Ethnic background of family and/or child: *

American Indian

African American

Asian

Spanish-American

Caucasian

Other

Decline to Answer