Preschool Enrollment

Enrollment Form

Columbia Presbyterian Preschool
After submission of enrollment form, please bring the following to the preschool office:
- Updated Immunization Form (MS Form 121)
- Notes from doctor regarding allergies or special needs
- Registration fee and tuition
* Communing members of Columbia Presbyterian Church are able to attend the preschool at half price. Members must be in good standing, weekly attenders, and active in the life of the church. *
Please Select All That Apply:

Registration Fee Paid 121 Form Submitted
Student Enrollment *

Full Time Part Time
After School Attendance *

Yes No
Summer Program (June - July) *

Yes No
Child's Information
Last Name *
First Name *
M.I. *
Birth Date *

Month Day Year
Gender *
Current Residence Information
Street Address *
Street Address Line 2 *
City *
State *
Zip Code *
Father's Information
Last Name
First Name
M.I.
Street Address
Street Address Line 2
City
State
Zip Code
Primary Phone Number

Area Code Phone Number
Is this a Cell Number?

Yes No
Email
example@example.com
Church Name Where You Attend: *
Are you a member of the church you attend? *

Yes No Not Applicable
How long have you been a member?
Employer:
Employer Address

Street Address

Street Address Line 2

City State

Zip Code
How long have you worked here?
Position
Paid

Hourly Salary
Annual Income
Mother's Information
Last Name
First Name
M.I.
Street Address
Street Address Line 2
City
State
Zip Code
Primary Phone Number

Area Code Phone Number
Is this a Cell Number?

Yes No
Email
example@example.com
Church Name Where You Attend: *
Are you a member of the church you attend? *

Yes No Not Applicable
How long have you been a member?
Employer:
Employer Address

Street Address

Street Address Line 2

City State

Zip Code
How long have you worked here?
Position
Paid

Hourly Salary
Annual Income
Family and Child Background Questions
Has the child attended another Preschool/Daycare in the past? *

Yes No
What is the name of prior Preschool/Daycare?
Do both parents reside in the same home? *

Yes No
Which parent does child primarily live with?

Father Mother
Does either parent not have legal parental rights? *

Yes No
Which parent does not have legal parental rights?

Father Mother
Are there any special circumstances occurring at home you would like to share with us? *

Yes No
Please Describe:
Legal Guardian's Information

(If child is not living with parents)
Last Name
First Name
M.I.
Street Address
Street Address Line 2
City
State
Zip Code
Primary Phone Number

Area Code Phone Number
Is this a Cell Number?

Yes No
Email
example@example.com
Church Name Where You Attend:
Are you a member of the church you attend?

Yes No
How long have you been a member?
Employer:
Employer Address

Street Address

Street Address Line 2

City State

Zip Code
How long have you worked here?
Position
Paid

Hourly Salary
Annual Income
Emergency Contacts (other than parents)
Emergency Contact 1
Last Name *
First Name *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *
Secondary Phone Number *
Relationship *
Emergency Contact 2
Last Name *
First Name *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *
Secondary Phone Number *
Relationship *
Emergency Contact 3
Last Name *
First Name *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *
Secondary Phone Number *
Relationship *
Individuals Authorized To Pick-Up Child
Are both parents authorized to pick up child? *

Yes No
Which parent is authorized and why?
Additional Authorized Individuals
Name

First Name Last Name
Name

First Name Last Name
Name

First Name Last Name
Child's Medical / Personal Information
Full Name of Child's Doctor
Doctor's Primary Phone Number
Doctor's Secondary Phone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Are there any medical or physical concerns? (I.E. Allergies, Physical Limitations, Ongoing Medicine, etc.) *

Yes No
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Siblings

	Name	Age	Date of Birth
Sibling 1
Sibling 2
Sibling 3

Permissions and Acknowledgements
MSDH Regulation Summary: I/We have received and read the MSDH Regulation Summary for parents (Part D on pages 4 & 5 of the student handbook)MSDH . *

Yes No
Immunization Compliance: a 121 Immunization Compliance Form is on file with Columbia Presbyterian Preschool *

Yes No
Payment Policy: There will be a $15 late fee charged after the 15th of the month if tuition and discovery fees have not been paid. A two (2) week written notification is required for withdrawal from the Preschool. Failure to meet this requirement will result in a charge of two (2) weeks tuition. *

Yes No
Potty-Trained: My child is trained and able to use the toilet on their own. *

Yes No
Breakfast Needs: My child will eat breakfast at Columbia Presbyterian Preschool. *

Yes No
Photos: I/We give permission to include my/our child in photos taken by either Columbia Presbyterian Church or Columbia Presbyterian Preschool for use in information materials, social media,or other community related purposes. *

Yes No
Emergency Medical Treatment: I/We authorize Columbia Presbyterian Preschool to administer emergency medical treatment (to include: medicine, compress, and bandages) or contact emergency services, if needed. *

Yes No
Field Trip Authorization: I hereby permit my child to participate in field trips sponsored by Columbia Presbyterian Preschool. I hereby release and hold harmless Columbia Presbyterian Church and its pastor and members, Columbia Presbyterian Preschool, the ministry team, teachers, aides, and chaperones from any and all liability for accidents, personal injury, property damage, etc., which may occur while my child is participating in these field trips. I understand that I will be notified in advance when each activity is planned so that I may approve of my child’s participation. *

Yes No
After School Pick-Up Authorization: In the event that my child needs to attend the Columbia Presbyterian Preschool After School Program, I/we authorize the staff to walk my child from his/her school. I understand that it is my responsibility to notify Columbia Presbyterian Preschool if my child will not be attending that day. *

Yes No
Please sign below using either your mouse or finger. If Signature block is not applicable please write N/A on line.
Signature of Father *

Clear
Signature of Mother *

Clear
Signature of Legal Guardian (If applicable) *

Clear
Should be Empty:

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Family and Child Background Questions

Legal Guardian's Information

Emergency Contacts (other than parents)

Individuals Authorized To Pick-Up Child

Child's Medical / Personal Information

Permissions and Acknowledgements