Preschool Registration Form

Mt. Calvary LutheranPreschool
Registration
Mt. Calvary Lutheran Preschool
6541 16th Ave. S.
Richfield, MN 55423
(612) 869-9441
www.mtcalvaryedu.org

Parent's Information:
Student lives with:*

Both ParentsFatherMotherOther
Please indicate who should be contacted first:*

FatherMother
Father's Name
Father's Email
example@example.com
Fathers Address if different from student

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Home Phone Number
Father's Work Phone Number
Father's Cell Phone Number
Mother's Name
Mother's Email
example@example.com
Mother's Address if different from student

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Home Phone Number
Mother's Work Phone Number
Mother's Cell Phone Number
If there is a separation or divorce custody situation of which we should be aware, please explain and provide a copy of the custodial agreement. We cannot deny a parent access to the child without court documentation on file.*
If no situation exists, enter "N/A"

Pick-Up Permission:
I hereby give my permission for my child to leave the preschool class with the persons named below. It is the responsibility of the parents to notify the preschool in writing of any changes.

Authorized Persons*

No person NOT named on this list will be allowed to pick up your child without your written permission.

Medical Background:
List any allergies that would pertain to preschool.*
If no allergies present, enter "N/A"
List any ongoing medical problems*
If no medical problems, enter "N/A"
List any dietary needs that would pertain to preschool*
If no dietary needs, enter "N/A"
Will medication ever need to be given during school hours?*

YesNo
If yes, a permission form will need to be completed.
Does student wear glasses?*
Yes or No
Does student have an IEP/ICCP?*
Yes or No

Choice of sessions (Please put an X in boxes for which you wish to enroll.)*

Parent Conferences:
Mt. Calvary Preschool will hold two parent conferences. The first conference will be held in October and the second conference will be held in April. During these conferences your child's teacher will discuss your child's social, emotional, and academic growth and Kindergarten readiness. These conferences are an excellent time to discuss any concerns or questions you may have regarding your child's growth.

Permission For Use Release:
I give permission for my child's work to be used in school related activities, displays, and publications.*

YESNO
parent's initials*
I give permission for my child's photo to be published electronically (preschool's website and Facebook pages) and/or on paper brochures.*

YESNO
parent's initials*
The staff of Mt. Calvary Lutheran Preschool shall not disclose a child's record to any person other than the child, the child's parent or guardian, the child's legal representative, employees of Mt. Calvary's preschool, and the commissioner unless the child's parent or guardian has given written consent or as otherwise required by law.

Release:
If emergency treatment is required, and the parents or legal guardian cannot be reached immediately, your signature in the space provided below empowers the school authorities to exercise their own judgement in calling the physician indicated, or if not available, to transport the child to a hospital emergency room. Likewise, your signature below is not sufficient for the release of confidential information protected by Federal Law.
Parent/Guardian signature*

Clear
Signature Date*

MonthDayYear
Date

How did you hear about us?
Mt. Calvary Lutheran Preschool accepts children of any race, color, national and ethnic origin to all the rights, privileges, programs and activities accorded or made available to the children at Mt. Calvary. It does not discriminate on the basis of race, color, religion, national and ethnic origin in the administration of its education policies, admission policies, and school-administered programs.
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Mt. Calvary LutheranPreschool