Preschool Registration

Preschool Registration

If you child is a new student at Midway PreK, you will need to upload an image of a birth certificate as well as an IEP (if applicable), in order to complete this registration. If your child is a returning student, you will not need these.

Child's Information
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Please upload a copy or picture of the child's birth certificate.
Child's Gender*
What size t-shirt does your child wear?
Which of the following options during the week is most preferred?*

3 year olds: Monday & Wednesday3 year olds: Tuesday & Thursday4 year olds: Monday through Wednesday4 year olds: Monday through Thursday

Parent & Household Information
Father's Name
Father's Cell

Area CodeNumber
Email
example@example.com
Father's Occupation
Father's Business Name & Address
Father's Work Phone

Area CodePhone Number
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Name
Mother's Cell

Area CodeNumber
Email
example@example.com
Mother's Occupation
Mother's Business Name & Address
Mother's Work Phone

Area CodePhone Number
Mother's Address (if different from father's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Email for Electronic Communication

Mother's EmailFather's Email
I give my child permission to participate in off-site field trips sponsored by the Pre-School.

YesNo
List the names and ages of any siblings.
List other adults living in the household
Do you have a home church you are actively engaged in? If so, what church? If not, just say, "No" or "None"

Child's Health
Allergies
Special Needs
Serious Accidents
Operations
Has the child had the following immunizations?

DPTPolioMeasles
Child's Physician
Physician's Phone Number

Area CodePhone Number
Does your child have either of the following?*

IEPA diagnosis that effects learningNeither
Please submit a copy of the IEP.*
Please explain your child's diagnosis. *
A Physical form signed by your child's physician is required to enter preschool and is due in our office by July 15th.
I give permission for my child to receive emergency medical treatment by the Charlotte County or Campbell County Rescue Squad.

YesNo

Child's Interests & Habits
What are your child's dominant INDOOR play interests?
What are your child's dominant OUTDOOR play interests?
Does your child eat well?
Does your child sleep or nap well?
Does your child cry easily?
Does the child separate from parents easily?
Is the child independent in his/her play habits?
What age did the child complete toilet training?
Is the child sensitive?
Does the child have imaginary playmates?
Is the child easily frustrated?
Does the child have playmates other than ones in school?
List any other information which will help us in working with your child so that he/she will feel safe and secure while in our care.

Read Carefully
Parent'(s) Marital Status
Does either parent have sole custody of the child?

YesNo
If you answered yes to the previous question, a joint statement and agreement or court order confirming sole custodial rights must be presented to the Prechool at Midway. *
Please list your name to state that you will send proof of custodial rights to the Preschool at Midway.

It is the responsibility of the parent to notify the Preschool at Midway if any of the above information changes during the school year.
Please e-sign here to certify that the information provided is accurate.
Please sign the parent's full name.
Please use the link/url below to submit your $60 registration fee OR mail a check made payable to Midway Baptist Church to the address below. Please put the child's name in the memo line.

https://www.paypal.com/us/fundraiser/charity/1460905

Mail check to:

Midway Baptist Church

2595 Midway Rd

Phenix, VA 23959
Should be Empty:

Child's Information