LKR Preschool Enrollment

Child's Name*

Gender*

BoyGirl

Nickname

Birthdate*

Date

Age (as of Sept 1, 2025)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone #*

Area CodePhone Number

Email*

example@example.com

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Class Preference: (please check one)

Checking a class below does not guarantee a spot in that class, however we will make every effort to honor your first choice.

Please select which class you are enrolling your child in:*

3 year old (must by 3 by Sept 1, 2025) - $100 per month3-4 year old (must be 3 by March 1, 2025) - $150 per month4-5 year old (must be 4 by Sept 1, 2025) $200 per month

3 Year old classroom (must be 3 by September 1, 2025) - $100 per month tuition

M/W A.M. - 9::00 - 11::30Tu/Th A.M. - 9::00 - 11::30

3-4 Year old classroom (must be 3 by March 1, 2025) - $150 per month tuition

T/W/Th A.M. - 9::00 - 11::30

4-5 year old classroom (must by 4 by September 1, 2025) - $200 per month tuition

M-Th A.M. - 9:00 - 11:30M-Th P.M. - 12:30 - 3:00

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Parent/Guardian Information:

Guardian/Parent Name*

Cell Phone #*

Area CodePhone Number

Work Phone #

Area CodePhone Number

Guardian/Parent Name*

Cell Phone #*

Area CodePhone Number

Work Phone #

Area CodePhone Number

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There are forms that are required for all students and must be turned in BEFORE your child's first day of attendance. Forms will need to be completed by both parent and child's physician. Forms will be emailed out at the beginning of June.

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Church Affiliation

How did you hear about our program?

_________________________________________________

A Non-Refundable Enrollment Fee of $80 is due at registration.

**This enrollment fee will hold your spot in the program**

Enrollment will be determined according to the date in which we receive both the online enrollment form AND enrollment fee. If we do not have a confirmed spot and your child is placed on the wait list for their specific room you will be notified by email and your enrollment fee will be returned.

If choosing to pay by check, make payable to South Rock Christian Church wih your child's name and LKR-Preschool on the memo line. Either drop off the check at the church office between 8:00am and 4:00pm M-F or mail to 900 S Rock Rd, Derby, KS, 67037.

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WAITLIST

At this time the specific classroom you have chosen has a waitlist. If an opening becomes available you will be contacted in the order submissions are received and the $80 non-refundable enrollment fee will be due at that time to hold your spot in the class.

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Payment Options

Pay now (credit-card)Pay later

Payment

LKR Preschool - Non-Refundable Enrollment Fee$80.00

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Little Kids Rock Preschool admits students of any race, color, national origin, and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. Little Kids Rock Preschool doesn't discriminate on the basis of race, color, national origin, and ethnic origin in administration of its educational policies and other school-administered programs.

2025-2026 Enrollment Form