ABC Pre-K Little Gators
Antioch Baptist Church (910-739-9425)
5089 Old Whiteville Road
Lumberton, NC 28358
Leslie Britt, PreK Director (910-674-0598), [email protected]
 

 
ABC PreK Application
 
 
Student’s Name: ___________________            Student will be called: _________________
 
Birthday: ______________________       Age: ___________________   Male/Female: ________
 
Address: ________________________________________
 
Mother’s Name: ____________________        Mother’s Cell #______________________
 
Mother’s Work & Work #: ___________________________________________________
 
Father’s Name: _______________________________        Father’s Cell #______________________
 
Father’s Work & Work #: _____________________________________________________
 
Parent’s Marital Status: Married _____   Divorced______   Separated_________ Other____________
 
Primary Caregiver: _______________________________
 
List 2 Emergency Contacts & Contact Phone #
 
1. ______________________________
 
2. ______________________________       
 
Student Allergies: _____________________________
 
List any information that you would like us to know about your child: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
 
 
Parent/Legal Guardian Signature: ________________________            Date: _______________________