Preschool Re-Enrollment

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. *
Please Select All That Apply:

Registration Fee Paid121 Form Submitted
Student Enrollment*

Full TimePart Time
After School Care*

YesNo
Summer Program (June - July)*

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
Is this a Cell Number?

YesNo
Email
example@example.com
Church Name Where You Attend:*
Are you a member of the church 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
Paid

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
Is this a Cell Number?

YesNo
Email
example@example.com
Church Name Where You Attend:*
Are you a member of the church 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
Paid

HourlySalary
Annual Income
Child and Family Background
Has there been any change to this section since original enrollment? (I.E. parents no longer live together, child resides with only one parent, loss of legal parental rights?)*

YesNo
What changes have taken place? Please be specific
Are there any special circumstances occurring at home you would like to share with us?*

YesNo
Please describe:
Legal Guardian's Information (if 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
Is this a Cell Number?

YesNo
Email
example@example.com
Church Name Where You Attend:*
Are you a member of the church 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
Paid

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
Are both parents authorized to pick up child?*

YesNo
Which parent is authorized and reason:
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)
Are there any medical or physical concerns? (I.E. Allergies, Physical Limitations, Ongoing Medicine, etc.)*

YesNo
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 .*

YesNo
Immunization Compliance: a 121 Immunization Compliance Form is on file with Columbia Presbyterian Preschool*

YesNo
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.*

YesNo
Potty-Trained: My child is trained and able to use the toilet on their own.*

YesNo
Breakfast Needs: My child will eat breakfast at Columbia Presbyterian Preschool.*

YesNo
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.*

YesNo
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.*

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
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.*

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:

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