COMMUNITY PRESBYTERIAN PRESCHOOL REGISTRATION 2020-2021
Date _______________ Gender______
CHILD’S NAME _____________________________________________ ________________
first middle last Nickname if applicable
ADDRESS _________________________________ HOME PHONE ________________
Street CELL PHONE _________________
__________________________________________ CHILD’S BIRTH DATE ____________
City, State Zip Code MONTH/DAY/YEAR
ENROLLING IN: (please check the class that applies)
[ ] Preschool (3 year old X 2 days/week) [ ] Pre-Kindergarten (4 year old X 2 days/week)
[ ] Preschool (3 year old X 3 days/week) [ ] Pre-Kindergarten (4 year old X 3 days/week)
[ ] *Preschool (3 year old X 5 days/week) [ ] Pre-Kindergarten (4 year old X 5 days/week)
* Contact the Director for additional information regarding our 3 year old 5 day per week programs.
PARENTS’ MARITAL STATUS: ____________________
MOTHER’S NAME _________________________ OCCUPATION ____________________
MOTHER’S WORK or Cell Phone # _________________
MOTHER’S ADDRESS (if different) _____________________________________________
FATHER’S NAME _________________________ OCCUPATION ____________________
FATHER’S WORK or Cell Phone # _________________
FATHER’S ADDRESS (if different) ______________________________________________
PARENTS’ HOME CHURCH/DENOMINATION ____________________________________
SIBLINGS (name and age) _____________________________________________________
PREVIOUS SCHOOL OR PROGRAM ATTENDED: please list facility name, dates, & address
PEDIATRICIAN OR FAMILY DOCTOR (name & phone) _____________________________
IS CHILD ON ANY MEDICATION? _____ IF YES, DESCRIBE ____________________
DOES CHILD HAVE ALLERGIES? _____ IF YES, DESCRIBE ____________________
PHYSICAL LIMITATIONS? _____ IF YES, DESCRIBE ____________________
SPECIAL NEEDS, HABITS, FEARS, ATTACHMENTS? ______________________________
PERSONS TO CONTACT IN CASE OF ILLNESS OR EMERGENCY OTHER THAN PARENT (These persons are also authorized to pick up my child)
1. _____________________________________________________________________ Name Relationship Phone
Name Relationship Phone
ANY INFORMATION YOU FEEL NECESSARY TO DISCLOSE, LIST ON BACK OF REGISTRATION FORM
Field Trip Permission
I _______________________________________, give my permission for my child
Print Parent or Guardian’s Name Here
_______________________________________, to go with his/her class on all field trips.
Print Child’s Name Here
I give this consent with the understanding that I will be notified in writing, prior to each field trip, of the time and location of each trip. I will have the authority at that time to deny my child consent to participate if I deem it necessary.
• All fees for field trips are included with the material fee at the time of enrollment.
• I will provide a car seat to be used on field trips.
Signature of Parent or Guardian
My child, ___________________________, has permission to attend gymnastics at Community Presbyterian Preschool. I agree to hold Community Presbyterian Church/Preschool and its staff harmless of liability.
Signature of Parent or Guardian
*If your child has any medical conditions, such as asthma or a physical disability that would inhibit them from participating, please discuss this with the Director.
Are you willing for your child’s name, address and phone number to be included on a roster that may be sent home to other parents upon their request, to be used for birthday parties, etc.? ____ Yes ____ No
Signature of Parent or Guardian
_____ Yes, please add our email address: _________________________________________
to receive the monthly preschool newsletter and any other notifications from the office.
Your email will not be shared with any other source and will only be used for the purpose of passing along schedule/activity related information from the director.
______ No, I/we prefer not to be contacted by email.
Student Media Inclusion: Occasionally we will share student photos, class photos, candid shots, video, on the church web site. Children’s names will not be included in any of the media.
Dear Parents of Community Presbyterian Preschoolers:
In order to ensure that our rates remain affordable, please be advised of the following conditions:
1. Tuition is based on an annual fee which may be paid in 10 monthly installments.
2. The first payment is due August 1, 2020 and the final payment will be due on May 1, 2021. If you are enrolling after the first day of school, your first payment will be due on the first day your child attends school and may be pro-rated depending on the day of enrollment.
3. All payments received after the 5th of the month, must include a $5.00 late fee. For each 10 days thereafter an additional $5.00 fee will be added to your account.
4. Full monthly installment is due regardless of attendance or school schedule.
5. Checks should be made payable to “Community Presbyterian Preschool” or “C.P.P” and may be delivered to the Preschool office.
6. A $12.00 fee will be assessed on any check returned for any reason.
7. Should a child withdraw from the roll, partial month’s tuition payments and material fees will not be refunded.
8. ANY questions regarding payments, amount due, or other concerns must be brought to the attention of the Director prior to the due date.
9. The Director and/or Treasurer have discretion over all money matters.
Please sign the bottom portion and return with your Registration Form.
I have read and understand the above terms and agree to adhere to the policies of Community Presbyterian Preschool as outlined above.
____ I will pay the entire annual tuition fees by August 1, 2020.
____ I will pay tuition in 10 monthly installments beginning August 1, 2020 and ending May 1, 2021.
Signature of Parent or Guardian Date
Child’s Name PRINTED
Community Presbyterian Preschool
Identity Verification Form
This information is required by Virginia State Law effective July 1, 1998. This form must be completed and on file in the Preschool office within 7 business days of the start of school.
Today’s Date: ______________________
Child’s Name:______________________ Child’s Date of Birth: __________________
Type of proof presented (must be one of the following):
________Birth certificate (must be a certified copy) or birth registration card
State: _____________________ Date Issued: _________________________
Birth certificate number: ___________________________________________
________Birth record/notification (hospital, physician or midwife record):
State: _____________________ Issuing agency/individual:______________
________Passport Issuing country: __________________________________________
Passport number: _______________________ Date Issued: ______________
________Placement agreement/record from agency: Date Issued: ______________
Issuing agency: _____________________ Case/Registration # _________
Previous Schools and/or Day Care Centers Attended:
Signature of responsible party providing information: ____________________________
Signature of Preschool Director/Assistant Director: ____________________________