Preschool Re-Enrollment

Re-Enrollment Form

Columbia Presbyterian Preschool

After submission of re-enrollment form, please bring the following to the preschool office:

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

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

YesNo

What changes have taken place? Please be specific

YesNo

Please describe:

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

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*

YesNo

Which parent is authorized and reason:

Additional Authorized Individuals

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

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

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

Please sign below using either your mouse or finger. If Signature block is not applicable please write N/A on line

Signature of Father*

Signature of Mother*

Signature of Legal Guardian (If applicable)*

Child and Family Background

Legal Guardian's Information (if not living with parents)

Emergency Contacts (other than parents)

Individuals Authorized To Pick-Up Child

Child's Medical / Personal Information

Permissions and Acknowledgements