CPC Preschool Registration Form 2022-23


Date _______________ Gender______

CHILD'S NAME _______________________________________________________________________________
first                                                     middle                                             last                                    Nickname if applicable

STREET ADDRESS ________________________ HOME PHONE ________________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) _____________________________________________________


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? ______________________________

-------------------------Emergency Contact Information on the back of this form----------------------

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 ________________ Address ________________________________________

2. Name ________________________________ Relationship _____________________ Phone ________________ Address ________________________________________

Any information you feel necessary to disclose, please list below.

Page 2 of 6

Date: ________________

Field Trip Permission

I give my permission for my child, _________________; to go with his/her class in the event of an opportunity to take a fieldtrip. Parents or Guardians will be notified weeks ahead of a scheduled fieldtrip.

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 a field trip would be 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

Physical Education

My child, ___________________________, has permission to participate in physical education class during preschool hours. I agree to hold Community Presbyterian Church/Preschool and its staff harmless of liability.

*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.
Signature of Parent or Guardian

Student Directory

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

Email Notification

_____ Yes, please add our email address(s): ________________________________________________
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.


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 full or in 10 monthly
2. The first payment is due August 1, 2022 and the final payment will be due on May 1, 2023. 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 your child's teacher or given to the Director. We also accept cash in the church office. The Preschool does not accept credit or debit cards.
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. Please provide us a 30 day notice of departure.
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.

Tuition Contract:

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 annual tuition fees by August 1, 2022.

____ I will pay tuition in 10 monthly installments beginning August 1, 2022.

_________________________________________ ________________
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:

Name: _________________________________________________________________
Location: _______________________________________________________________

Name: _________________________________________________________________
Location: _______________________________________________________________

Signature of responsible party providing information: ____________________________

Signature of Preschool Director/Assistant Director: ____________________________

Community Presbyterian Preschool
Corona Virus/COVID-19 Waiver

The undersigned acknowledges that the coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Community Presbyterian Preschool has taken steps to implement certain recommended guidance and protocols issued by the Centers for Disease Control and Prevention (CDC). However, the undersigned understands and acknowledges both the known and potential dangers of my child attending Community Presbyterian Preschool, despite our reasonable efforts to mitigate such dangers, resulting in exposure to COVID-19, which could result in illness, disability, and/or death.

The undersigned agrees to assume all of the foregoing risks, accept sole responsibility and will not hold Community Presbyterian Preschool, Community Presbyterian Staff or Community Presbyterian Church liable for any consequences as it relates to COVID-19.

I have read and understand the terms of this Assumption of Risk, Release and Waiver of Liability Agreement.

Child’s Name-printed: _________________________

Parent’s Name-printed: _________________________

Parent’s Signature: ____________________________ _____________________________

Date: ________________