Preschool Enrollment

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. *
Registration Fee Paid121 Form Submitted
Full TimePart Time
YesNo
YesNo
Child's Information
Last Name*
First Name*
M.I.*
Birth Date *

MonthDayYear
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 CodePhone Number
YesNo
Email
example@example.com
Church Name Where You Attend:*
YesNoNot Applicable
How long have you been a member?
Employer:
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
How long have you worked here?
Position
HourlySalary
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 CodePhone Number
YesNo
Email
example@example.com
Church Name Where You Attend:*
YesNoNot Applicable
How long have you been a member?
Employer:
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
How long have you worked here?
Position
HourlySalary
Annual Income
Family and Child Background Questions
YesNo
What is the name of prior Preschool/Daycare?
YesNo
FatherMother
YesNo
FatherMother
YesNo
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 CodePhone Number
YesNo
Email
example@example.com
Church Name Where You Attend:
YesNo
How long have you been a member?
Employer:
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
How long have you worked here?
Position
HourlySalary
Annual Income
Emergency Contacts (other than parents)
Emergency Contact 1
Last Name*
First Name*
Address*

Street Address

Street Address Line 2

CityState

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

Street Address

Street Address Line 2

CityState

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

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Secondary Phone Number*
Relationship*
Individuals Authorized To Pick-Up Child
YesNo
Which parent is authorized and why?
Additional Authorized Individuals
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast 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)
YesNo
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Siblings

Rows	Name	Age	Date of Birth
Sibling 1
Sibling 2
Sibling 3

Permissions and Acknowledgements
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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.*

YesNo
YesNo
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:

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