Wien's Registration Form
Wien Private Day School
916 Ninovan Road, S.E.
Vienna, Virginia 22180
703-281-3172
1998-99 Fall Registration Form
Child's Name
Nickname
Sex
Male
Female
Birth Date
Address
Home Phone
Father's Name
Place Employed
Bus. Phone
Address (if different)
Father Home Phone
Mother's Name
Place Employed
Bus. Phone
Address (if different)
Home Phone
Name of Person(s) or agency having legal custody of child
Address (if different)
Home Phone
Name of Child's Physican
Phone
List all medications child is currently taking
My child has the following allergies (write none if applicable)
Name of Emergency Contact (not parents)
Realtionship To Child
Address
Phone
Name of Emergency Contact (not parents)
Realtionship To Child
Address
Phone
Persons NOT Authorized to pick up child
Other schools child attends
Grade
Phone
Do you authorize the center to allow the children to participate on duly authorized field trips when feasible
Yes
No
Wien Private Day School will notify the Parent/Guardian whenever child becomes ill.
The Parent/Guardian will pickup child as soon as possible.
Yes
No
The Parent/Guardian authorizes Wien Private Day School to obtain immediate medical care
if any emergency occurs when he/she cannot be located immediately
Yes
No
Mother's E-Mail Address
Father's E-Mail Address
Comments
