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St Columbkill Parish
200 Indian Spring Road, Boyertown, PA 19512
610 367-2371 - Fax 610 369-0242
Preschool Program Registration Form
Child must be 3 or 4 years by September 10th of the year you are applying for.
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Family Address
Primary Family Address
Family Name
Address
Primary E-mail
This will be the main e-mail address we will use to communicate with your family.
Primary Phone
This will be the main phone number we will use to communicate with your family.
Number of Children
1
2
3
4
5
Number of Children you will be registering today
Number of Children (Alternate Pricing)
1
2
3
4
5
Number of Children you will be registering today
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Father / Guardian
Name
Deceased
Yes
No
E-mail
Marital Status
Married
Divorced
Separated
Single
Widower
Religion
Cell Phone
Mother / Guardian
Maiden Name
Name
Deceased
Yes
No
E-mail
Marital Status
Married
Divorced
Separated
Single
Widow
Religion
Cell Phone
Custody Information
Are there any custody issues we should be made aware of? If there is a custody agreement please send a copy to the Religious Education Department.
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Child 1
Name
Gender
Male
Female
Date of Birth
Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)
Medical/Learning Data
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 1 Session Choice
Child 1 Session Choice
Age 3 - Mon & Wed 9:00-11:30 am
Age 3 - Tue & Thu 9:00-11:30 am
Age 4 - Mon, Wed, Fri 9:00-11:30 am
Age 4 - Tue, Thu, Fri 9:00-11:30 am
Child 2
Name
Gender
Male
Female
Date of Birth
Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)
Medical/Learning Data
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 2 Session Choice
Child 2 Session Choice
Age 3 - Mon & Wed 9:00-11:30 am
Age 3 - Tue & Thu 9:00-11:30 am
Age 4 - Mon, Wed, Fri 9:00-11:30 am
Age 4 - Tue, Thu, Fri 9:00-11:30 am
Child 3
Name
Gender
Male
Female
Date of Birth
Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)
Medical/Learning Data
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 3 Session Choice
Child 3 Session Choice
Age 3 - Mon & Wed 9:00-11:30 am
Age 3 - Tue & Thu 9:00-11:30 am
Age 4 - Mon, Wed, Fri 9:00-11:30 am
Age 4 - Tue, Thu, Fri 9:00-11:30 am
Child 4
Name
Gender
Male
Female
Date of Birth
Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)
Medical/Learning Data
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 4 Session Choice
Child 4 Session Choice
Age 3 - Mon & Wed 9:00-11:30 am
Age 3 - Tue & Thu 9:00-11:30 am
Age 4 - Mon, Wed, Fri 9:00-11:30 am
Age 4 - Tue, Thu, Fri 9:00-11:30 am
Child 5
Name
Gender
Male
Female
Date of Birth
Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)
Medical/Learning Data
*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."
Child 5 Session Choice
Child 5 Session Choice
Age 3 - Mon & Wed 9:00-11:30 am
Age 3 - Tue & Thu 9:00-11:30 am
Age 4 - Mon, Wed, Fri 9:00-11:30 am
Age 4 - Tue, Thu, Fri 9:00-11:30 am
Authorized Contacts
For your child's protection, please fill out the names of all persons authorized including yourself to take your child from Pre-Kindergarten. Please inform any authorized person to be prepared to identify themselves and show proper identification. Anyone not on this list is NOT AUTHORIZED to pick up your children.
Include Full Name, Phone Number & Relationship
List any permanent car pool arrangements. Please write a note to the classroom teacher if there are any changes to the permanent arrangement.
Include Full Name, Phone Number & Relationship
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Emergency Contact
Emergency Contact Name
If we are unable to contact a parent in the event of an emergency, whom should we contact?
Relationship
Emergency Contact Phone
Doctor
Doctor's Name
Doctor's Phone
Terms & Conditions
In case of an emergency involving my child and no contact as indicated on the registration form can be reached, I/We give permission to Pre-Kindergarten personnel to arrange for my child to be taken to the hospital should the need arise. I/We authorize hospital medical personnel to administer any necessary medical care.
I agree
Current Date
Additional Fee
An additional fee of $25.00 will be added after August 31, 2018
Total Normal
Total Amount
Verification
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