Fall Registration 2026-2027

Registration Fall 2026-2027
Perspective Requirements for Classrooms

Toddler Room	Must be 12 Months by November 1 of enrollment year
Two's Room	Must be two (2) years of age by December 1 of enrollment year
Preschool A	Must be three (3) years of age by December 1 of enrollment year
Preschool B	Must be three (3) years of age by September 1 of enrollment year Must be potty trained or working towards potty trained (no diapers)
Preschool C	Must be four (4) years of age by December 1 of enrollment year Must be potty trained (no diapers or training pants)
Pre-K	Must be four (4) years of age by September 1 of enrollment year and be assessed as to readiness Must be potty trained (no diapers or training pants)

Your application is complete when the following is turned into office:
- Enrollment Form Completed
- Emergency Forms and Releases signed and completed
- Copy of Immunization Records
- Immunization Exemption Request Form (if applicable); Supporting Documentation including Doctor's note must be submitted with request
- $100 non-refundable deposit paid
- Financial Form signed and completed

Student Information
Student's Name*

First NameMiddle NameLast Name
Class Interested*
MondayTuesdayWednesdayThursdayFriday
Preferred Name*
MaleFemale
Birthdate*

MonthDayYear
Date
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

PARENT INFORMATION
Mother's Full Name*

First NameMiddle NameLast Name
Place of Employment
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Father's Full Name*

First NameMiddle NameLast Name
Place of Employment
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code

RELATIVE INFORMATION
Siblings

Enter sibling information (if applicable)

Rows	First Name	Last Name	Age	Attending St. Elijah?
Sibling 1
Sibling 2
Sibling 3
Sibling 4

Grandparents

Enter grandparent information (if applicable)

Rows	First Name	Last Name
Maternal Grandmother
Maternal Grandfather
Fraternal Grandmother
Fraternal Grandfather

AUTHORIZATIONS / RELEASES
EMERGENCY CONTACTS

In the event of an emergency please list two (2) people, other than parents, who would be willing and able to come pick up your child in the event that St. Elijah staff were unable to reach the parents.
Emergency Contact #1*

First NameLast Name
Relationship to Child*
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact #2*

First NameLast Name
Relationship to Child*
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
AUTHORIZED TO TAKE CHILD FROM THE FACILITY

Please list any persons you wish to authorize to take child from facility without other written consent.
Authorized Person 1

First NameLast Name
Relationship to Child
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 2

First NameLast Name
Relationship to Child
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 3

First NameLast Name
Relationship to Child
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
DO NOT RELEASE (if applicable)

Do not allow my child to be released to the following people:
Do Not Release to Person 1

First NameLast Name
Relationship to Child
Do Not Release to Person 2

First NameLast Name
Relationship to Child

AUTHORIZATION FOR EMERGENCY TREATMENT / MEDICAL CARE
In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the Director of St. Elijah MDO & Pre-K or designated staff appointed by the Director to take my child or to have my child transported by Emergency Medical Services (911) to:
Child's Physician
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Hospital
Address

Street Address

Street Address Line 2

CityState

Zip Code
I give permission for necessary emergency treatment when my child is in the care of this physician and/or hospital/clinic:
Parent Authorizing Full Treatment*

First NameLast Name
Parent Signature*

Clear
Signature Date

MonthDayYear
Date

CHILD'S MEDICAL HISTORY
List any known medical conditions
List any serious injuries / hospitalizations child has had in the past 12 months
YesNo
YesNo
List allergies and restrictions

List all medicines your child is currently taking (Include as needed medications and vitamins)

Rows	Medication Name	Dosage	Frequency
Medicine 1
Medicine 2
Medicine 3
Medicine 4
Medicine 5
Medicine 6

ALL IMMUNIZATION EXEMPTION REQUESTS MUST BE SUBMITTED AT TIME OF APPLICATION. Entrance into the school is subject to approval of requested exemption.

If any changes occur please let us know immediately.

CLASS LIST AND PHOTOGRAPH PERMISSIONS
CLASS LIST

Phone, address, email lists will be given out by request only, and are to be used solely for purposes such as organizing play groups, or mailing invitations, etc. They will not be given out for any commercial purposes.
I hereby give my permission for distribution of my address, phone number and/or email address to any other parent of a child enrolled in my child’s class at St. Elijah Mom’s Day OutI hereby do not give my permission for distribution of my address, phone number and/or email address to any other parent of a child enrolled in my child’s class at St. Elijah Mom’s Day Out
Parent Granting Permission*

First NameLast Name
Parent Signature*

Clear
PHOTOGRAPHS

From time to time, St. Elijah Mom’s Day out will photograph your child for use in classroom activities, parent events, or for use on our website.
I give permission for St. Elijah Mom’s Day Out to photograph my child for use outlined in paragraph aboveI give permission for my child’s teacher to take photographs of my child for use in Art/Classrooms activities that may arise during the school yearI DO NOT wish to have my child photographed while attending St. Elijah Mom’s Day Out
Parent Granting or Not Granting Permission*

First NameLast Name
Parent Signature*

Clear

Registration Fall 2026-2027

Perspective Requirements for Classrooms

Student Information

PARENT INFORMATION

RELATIVE INFORMATION

Siblings

Grandparents

AUTHORIZATIONS / RELEASES

AUTHORIZATION FOR EMERGENCY TREATMENT / MEDICAL CARE

CHILD'S MEDICAL HISTORY

CLASS LIST AND PHOTOGRAPH PERMISSIONS

ALL ABOUT ME