PVUMCC Registration Form

United Methodist Church 1565 Washington Blvd., McKeesport, PA 15133

Port Vue United Methodist Church Christian Preschool

Use this form to apply for the PVUMCC Preschool. The Preschool is located at Port Vue UMC, 1565 Washington Blvd, McKeesport, PA 15133 If you have any questions, please call PVUMC (412) 672-7289
Child's Last Name*
Child's First Name*
Child's Middle Name
Nickname (if you prefer the teacher use this name)
Date of Birth

MonthDayYear
Date
Sex*

MaleFemale
Child's Age as of September 1: *Please Note: All students must be toilet trained**
Address*
Primary Phone Number *
Secondary Phone Number*
Email*
example@example.com
Father's Name*
Occupation*
Place of Employment*
Mother's Name *
Occupation*
Place of Employment*
Child Lives with*

Both ParentsMotherFatherOther (please specify below)
Other (if not applicable, please write None)*
If none of the above, please explain the child's living situation (if not applicable, please write None)*
List all siblings, names and ages (if not applicable, please write None) *
Date of Child’s Last Physical Exam*

MonthDayYear
Date
Family Doctor*
Condition of health*
List any allergies or physical problems (if not applicable, please write None)*
List any emotions needs or problems that your child has that the teacher would need to be aware of (if not applicable, please write None)*
Has your child attended Preschool before?*

YesNo
If yes, where did your child attend Preschool?
Please, Indicate Your Choice of Class Time Below

3 YEAR OLD - TUESDAY, THURSDAY | 4 YEAR OLD - MONDAY, WEDNESDAY, FRIDAY
Preferred Class Time*

Morning (9:30am – 12:00pm)Afternoon (1:00pm – 3:30pm)
IN THE EVENT OF AN EMERGENCY, PLEASE LIST THE NAME OF LOCAL PERSONS WHO CAN PICK UP YOUR CHILD IF PARENTS CANNOT BE REACHED. Contact Name #1*
Phone Number of Contact #1 *
Contact Name #1 Relationship*
Contact Name #2*
Phone Number of Contact #2*
Contact Name #2 Relationship*
*Your signature below will serve as your agreement*
PERMISSION FOR MEDICAL TREATMENT I GIVE PERMISSION TO HAVE MY CHILD TRANSFERRED TO THE HOSPITAL AND RECEIVE MEDICAL ATTENTION. I WILL ASSUME FULL RESPONSIBILITY FOR CHARGES RELATED TO THE ABOVE. Parent/Guardian Signature for Medical Treatment*

First NameLast Name
PHOTO/VIDEO RELEASE FORM I GIVE PERMISSION FOR PORT VUE UNITED METHODIST CHURCH CHRISTIAN PRECHOOL TO VIDEO AND PHOTOGRAPHMY CHILD. I UNDERSTAND THAT THESE PHOTOGRAPHS COULD BE POSTED ON THE PVUMC WEBSITE, SOCIAL MEDIAPAGES OR USED IN BROCHURES OR FLYERS. Parent/Guardian Signature for Photo/Video Release*

First NameLast Name
APPLICATION FORM ACCURACY ALL INFORMATION COMPELTED ON THE APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. Parent/Guardian Signature for Application For Accuracy*

First NameLast Name
Today's Date*

MonthDayYear
Date
Are you an active member of a church, and if so, where? (if not applicable, please write None)*
Would you like to receive church mailings?*

YesNo
Should be Empty:

Please, Indicate Your Choice of Class Time Below