Preschool Registration

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

Number of Children you will be registering today

Number of Children (Alternate Pricing)

Number of Children you will be registering today

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Father / Guardian

Name

Deceased

Yes No

E-mail

Marital Status

Religion

Cell Phone

Mother / Guardian

Maiden Name

Name

Deceased

Yes No

E-mail

Marital Status

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

Age 3 - Mon & Wed 9:00-11:30 am (This class is full) Age 3 - Tue & Thu 9:00-11:30 am Age 4 - Mon & Wed & Fri 9:00-11:30 am (This class is full) Age 4 - Tue & Thu & Fri 9:00-11:30 am (This class is full)

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

Age 3 - Mon & Wed 9:00-11:30 am (This class is full) Age 3 - Tue & Thu 9:00-11:30 am Age 4 - Mon & Wed & Fri 9:00-11:30 am (This class is full) Age 4 - Tue & Thu & Fri 9:00-11:30 am (This class is full)

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

Age 3 - Mon & Wed 9:00-11:30 am (This class is full) Age 3 - Tue & Thu 9:00-11:30 am Age 4 - Mon & Wed & Fri 9:00-11:30 am (This class is full) Age 4 - Tue & Thu & Fri 9:00-11:30 am (This class is full)

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

Age 3 - Mon & Wed 9:00-11:30 am (This class is full) Age 3 - Tue & Thu 9:00-11:30 am Age 4 - Mon & Wed & Fri 9:00-11:30 am (This class is full) Age 4 - Tue & Thu & Fri 9:00-11:30 am (This class is full)

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

Age 3 - Mon & Wed 9:00-11:30 am (This class is full) Age 3 - Tue & Thu 9:00-11:30 am Age 4 - Mon & Wed & Fri 9:00-11:30 am (This class is full) Age 4 - Tue & Thu & Fri 9:00-11:30 am (This class is full)

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

Total Normal

Total Amount

Verification