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The Premier Centers
Hegewisch-East Side
Near The Pier STEAM Development Center
Pill Hill
West Austin
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East Side
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Pill Hill
West Austin
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Child Details
First Name
Last Name
Mother's Name
Father's Name
Date of Birth
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Male
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Last 4 digit of Child's SSN
Siblings
Name
Age
Family Address
Street Address
City
State/ Province/ Region
Postal/ Zip Code
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Home Phone
Email Address
How many years at this Address?
Previous Address
Street Address
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Postal/ Zip Code
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Mother's Business
Street Address
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State/ Province/ Region
Postal/ Zip Code
Country
Phone
Father's Business
Street Address
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Postal/ Zip Code
Country
Phone
Medical Information
Family Doctor
Clinic Name
Clinic Phone
Street Address
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Postal/ Zip Code
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Medical Insurance
Name
Phone
Street Address
City
State/ Province/ Region
Postal/ Zip Code
Country
Emergency Information
Individual, other than parent, to be called in case of emergency:
Name
Phone
Street Address
City
State/ Province/ Region
Postal/ Zip Code
Country
Individuals authorized to pick up my child:
Full Name
Child History
Nichname, If any
Who does your child live with?
Mother
Father
Legal Guardian
Other
Is your child toilet trained?
Yes
No
Is your child adopted?
Yes
No
Comment on child's appetite and food interest.
Is child allergic to any foods or drinks
Does your child have medical alerts that the center needs to be aware of?
Is there a particular learning style your child has exhibited?
Please share with us anything you are particularly proud or excited about that your child can do.
Guardian's Email
Guardian's Full Name
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infant education
toddler education
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school age education
parent handbook
