2023-24 Preschool Enrollment Form

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Relation to Student*

Emergency Contact 2*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Relation to Student*

Doctor*

Name of Office

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Dentist*

Name of Office

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Hospital*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

In the case of an emergency, the police or paramedics may take your child to the nearest hospital for medical treatment. There may be a charge for ambulance service. Do you authorizes program staff to use emergency services if necessary, and indicates your agreement to the above mentioned hospital policy.*

Yes, I agree

Should Poison Control need to be contacted, and upon their advice, we may administer Syrup of Ipecac to your child to counter-effect an ingestion of poison. Do you give program staff permission to follow this policy.*

Yes, I agree

Ethnic Affiliation (for statistical purposes only):

Primary Language Spoken at home:*

Links to preschool policies and Maltreatment of Minors Mandated Reporting can be found here.

Policies and Releases: I agree that I have received a copy of the program policies and agree to abide by these guidelines.*

Yes, I agree.

I have received a copy of Maltreatment of Minors Mandated Reporting.*

Yes, I agree.

Are there any additional children in the household? Please list their names and date of birth. This information will be used to alert you of preschool and school enrollment opportunities and/or events for younger siblings.

Signature*

Clear

Name of person completing this form:*

First NameLast Name

Below is an option to pay the registration fee online. You may also choose to pay the school directly by cash or check. The fee is $125 per family.

Preschool Registration Fee

$125.00

Enter coupon

Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Preschool Enrollment Form - 2023-2024 School Year

Parent/Guardian 1

Parent/Guardian 2

Contract Information