Admission Form 2022-23

You will be invoiced through Procare for your registration fee.

Please Note: The enrollment is not complete until this form has been submitted and the registration fee has been paid.

Choose class (age as of Sept. 1, 2022)

Choose Days

Afternoon Enrichment (18 mo. - 3 years)

Church Member

Child's First Name

Child's Preferred Name/Nickname

Child's Last Name

Date of Birth

Date

Male Female

Address

Home Address

Street Address Line 2

City

Zip Code

Age on September 1, 2022

Primary Email Address

Secondary Email Address (optional)

Parent/Guardian First Name

Parent/Guardian Last Name

Cell Phone

Work Phone

Parent/Guardian Occupation

Work Place

Parent/Guardian First Name

Parent/Guardian Last Name

Cell Phone

Work Phone

Parent/Guardian Occupation

Work Place

Siblings

Emergency Contact Information (If unable to reach parent/guardian)

First and Last Name

Relationship

Primary Phone Number

Please enter a valid phone number.

Authorized Student Pick Up Release

I hereby authorize First Presbyterian Preschool of Grapevine to allow my child/children to leave the school with only the persons listed below. In the event that a person not listed below is designated to pick up my child, I understand that First Presbyterian Preschool of Grapevine must receive a phone call from one of the approved parents or legal guardians and a copy of their license must be made and filed in my child's registration folder.

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Please enter a valid phone number.

Allergies/Health Conditions/Dietary Restrictions

List any health conditions that your child may have, such as allergies, existing conditions, existing illness, previous illness, and/or injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other health information of which the staff should be aware in the space below. If your child has any dietary restrictions, please list them below as well.

If your child does not have allergies, health concerns or dietary restrictions, please write NONE.

Immunization Records, Physician's Statement and Hearing and Vision

Immunizations Records must be turned in at the time of registration. The Physician's Statement does not need to be completed at the time of registration. This form is due to the preschool office by September 1st, 2022. Physician Statements expire one year from the date signed.

All children who are 4 years of age by September 1st, 2022 must have a signed hearing and vision screening along with the Physician's Statement.

Failure to comply with these Texas State Regulations will result in your child being unable to attend school until these forms are completed and on file.

I have read the Parent Handbook from First Presbyterian Preschool of Grapevine and agree to hold to the policies stated in the handbook.

Parent/Guardian Signature Clear

Date

Authorization for Emergency Medical Attention:

In the event I cannot be reached to make arrangements for medical treatment I authorize any representative of First Presbyterian Preschool of Grapevine to administer first aide and/or to call 911 to transport my child to Baylor Medical Center at Grapevine 1650 West College Grapevine, Texas 76051, 817-488-7546. I authorize and give my consent for any necessary medical treatment, emergency or otherwise furnished by a licensed physician, hospital or emergency treatment clinic. My healthcare provider and I agree to pay for all medical fees incurred in connection with the treatment of my child under the authority granted within. I hereby release First Presbyterian Preschool of Grapevine and any healthcare provider and any other respective agents, employees, officers or representatives from any and all liability for action of my child pursuant to the terms of this

Parent/Guardian Signature

Clear

Date

The following information is needed for emergency treatment. All information is kept in the child's confidential file in the office.

Child's Physician

Physician's Phone Number

Health Insurance

Phone Number

Policy Number

Group Number

Release Statements

Child's Name

Throughout the school year, we take photographs of the children while they are in attendance at First Presbyterian Preschool of Grapevine. We will use these photographs for classroom activities (class books, bulletin boards, cubby displays etc, the children's end of the year memory books given to parents, teacher and office newsletters, preschool website, preschool Facebook page, church Narthex screens viewed during church special events celebrating the preschool, as well as church newsletters. No names will be used for any pictures shared with the public outside our preschool. First Presbyterian Preschool of Grapevine understands that parents will also want to take photographs and videos of the children during preschool hours and events. This is permissible with the understanding that for the privacy and safety of our students, we ask that you refrain from publishing photographs/videos of First Presbyterian Preschool of Grapevine students, other than your own child, on any social media outlets such as Facebook, Twitter, Instagram, Pinterest, personal blogs etc. Finally, some families have requested that their child not be photographed in any capacity while attending school. For this reason, a staff member or teacher may ask that you refrain from photographing/videoing

Use of Photography: I understand that the policy of First Presbyterian Preschool of Grapevine states that parents of enrolled students are allowed to take photographs and/or video of the children who have parental consent while they are at the preschool. I also understand that as a parent of an enrolled student I am not to use pictures and/or video which contain students, other than my own child, in any social media outlets such as Facebook, Twitter, Instagram, Pinterest, personal blogs etc. I also agree to hold First Presbyterian Preschool of Grapevine harmless in any lawsuit based on failure of other parents to take reasonable steps to prevent such publication. I also understand that a staff member or teacher may ask that I refrain from photographing/videoing.

I hereby give permission for my child's picture to be taken and used for the purpose of (choose all that apply):

Parent/Guardian Signature

Clear

DIRECTORY: I give my consent to be included in the preschool directory, including my child's name, home address, home phone number and email.

Yes No

WATER ACTIVITIES: I hereby give my consent for my child to participate in indoor and outdoor water activities.

Yes No

COUNTRY CRITTER PONY RIDES: I hereby give my consent for my child to ride a pony on school property with staff and/or event person supervision. This event is scheduled once a year in October for each morning program.

Yes No

SNACKS AND LUNCH BUNCH: I do not hold First Presbyterian Preschool responsible for the snacks and lunches that are sent to the preschool from home.

Yes No

Parent/Guardian Signature

Clear

Date