Kailua Methodist Preschool

1110 Kailua Road  Kailua, HI 96734

Phone: 262-7674


Application Form

Today's Date


Child's Name


Sex: M / F     Date of Birth:

Parent/Guardian Name(s)


Home address________________________________________________________ City/Zip_______________________________

Home Phone__________________________  E-Mail Address:_______________________________________________________

Mother/Guardian cell_______________________________     Father/Guardian cell______________________________________


Are you a member of Kailua United Methodist Church?  Yes / No


Parent/Guardian Employment Information:

Father/Guardian: _________________________________________________________________________________________

                                                   (Company Work Name and Address)                                                              (Work Phone)


Mother/Guardian: _________________________________________________________________________________________

                                                   (Company Work Name and Address)                                                               (Work Phone)


Person to contact (other than parents) in case of emergency:

Name______________________________________ Phone: 1)_______________________ 2)___________________________

Name______________________________________ Phone: 1)_______________________ 2)___________________________

List any and all allergies, physical or medical difficulties your child has:



Has your child ever attended another preschool? Yes / No

If yes, Name of Preschool: _________________________________________________ City/State ________________________

How long did they attend? ________________ Reason for withdrawal: _______________________________________________

Schedule preferred: (please mark a 1st and 2nd choice)

M-F (5 days)                8:00-12:30 _____     7:00-3:30 _____                          Start Date:


M, W, F (3 days)          8:00-12:30 _____     7:00-3:30 _____

T, TH (2 days)             8:00-12:30 _____     7:00-3:30 _____


Office Use Only

Application Fee____       Registration Fee ____ Tuition Deposit ____             Annual Comp. Fee ____      Emergency Card ____

Birth Cert. (copy) ____       Hawaii Form 14 ____             TB Record     ____             DTaP (4)               ____       Hib ____

Polio-IPV (3)        ____       Hep B               ____             MMR (1)           ____             Varicella (1)         ____      Form 908________

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