The Tabernacle Learning Center of Danville, Inc.

1978 South Boston Road, Danville, VA, 24540

 

PRINT THIS FORM- FILL IT OUT- MAIL BACK TO THE ADDRESS ABOVE

Student Name ________________________________________________  Phone Number _____________________________

Address __________________________________________________________________

City/State/Zip ____________________________________________________________

Date of Birth ________________      Place of Birth _________________      Birth Certificate # ________________________

Enrolling in: Kindergarten 3 ______     Kindergarten 4 ______     Kindergarten 5 ______

Number of days:  Monday-Friday ______     M/W/F ______     T/Th ______

 

Father's Name __________________________________  Phone Number ____________________________

Address (if different from above) ___________________________________ City _______________ State ______ Zip ______

Employer _____________________________  Phone Number _____________________________

Employer Address _____________________________________________  City ____________ State _____ Zip _____

 

Mother's Name __________________________________  Phone Number ____________________________

Address (if different from above) ___________________________________ City _______________ State ______ Zip ______

Employer _____________________________  Phone Number _____________________________

Employer Address _____________________________________________  City ____________ State _____ Zip _____

 

Are parents: Married and living together ______      Separated ______      Divorced ______

If parent(s) is/are not living, state name and relationship of guardian. _____________________________________________

Who has custody of applicant? ___________________________________

Please send mail to : Home address ______      Business ______      Other ___________________________________________

Church Attending ____________________________________________________________________

Pastor's Name ______________________________________

Please check services attending on a regular basis:

____Sunday School     _____Morning Worship     _____Sunday Evening Service     _____Mid Week Service

List any allergies __________________________________________________________________________________________

List any medications _______________________________________________________________________________________

Physician to call in case of emergency __________________________________  Phone _______________________________

Emergency Friend __________________________________________  Phone __________________________________

 

 A $100.00 NON-REFUNDABLE REGISTRATION FEE MUST ACCOMPANY THE APPLICATION FOR ADMISSION. IF NOT ACCEPTED, REGISTRATION FEE WILL BE RETURNED.