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Ascension Lutheran Preschool Registration Form for 2009-2010
Child’s Name_______________________________________________ Birthday______________
Address_______________________________________________________________________________________________ Address City Zip Code
Class you are enrolling for:
Two School (Toddler class for 2’s) ________ Two School (Toddler class for 2’s) _________ M/W 9:00-11:30 Tu/Th 9:00-11:30 $95.00/month $95.00/month
Preschool (3 year olds) ________ Tu/Th 9:00-11:30 $90.00/month
Pre-K (4 yr olds) ______ Pre-K (4 yr olds) _______ Pre-K (4 yr olds) _______ M,W,F 8:45-11:45 M,W,F 9:00-12:00 M,T, Th 12:30-3:30 $110.00/month $110.00/month $110.00/month
Pre-K (4yr olds) _____ M,TuWTh 9:00-11:30 $125.00/month
Mother’s/Guardian’s Name________________________________________________________________________________
Address ___________________________________________________________________________________________________ Address City Zip Code
Phone #’s __________________________________________________________________________________________________ Home Cell Work
Place of Employment_______________________________________________________________________________________
Father’s/Guardian’s Name_________________________________________________________________________________
Address _________________________________________________________________________________________________ Address City Zip Code
Phone #’s _________________________________________________________________________________________________ Home Cell Work
Place of Employment_______________________________________________________________________________________
Please indicate who child lives with: Both parents Father Mother Other (Please explain)
Please list names and ages of siblings:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Persons to contact in case of emergency if parents cannot be reached:
________________________________________________________________________________________________________________ Name Relationship to student Address Phone
________________________________________________________________________________________________________________ Name Relationship to student Address Phone
I hereby authorize Ascension Lutheran Preschool to allow my child to leave with the following persons:
________________________________________________________________________________________________________________ Name Name Name
________________________________________________________________________________________________________________ Name Name Name
Please list any special needs or medical conditions that your child may have such as allergies, asthma, seizures, an existing illness, a previous serious illness, injuries during the past months, medication prescribed for long-term use, or other information the staff should be aware of:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Please list any special dietary requirements your child has:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Please list guidance and discipline techniques used at home with your child:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Please list any other information about your child that may be helpful to us, i.e., likes and dislikes, personality attributes, etc.:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
AUTHORIZATION FORM EMERGENCY MEDICAL TREATMENT
In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the Ascension Lutheran Preschool Director or person in charge to take my child to the following for necessary treatment:
Physician______________________________________________________________________________________________ Name Address Phone
Hospital _______________________________________________________________________________________________ Name Address Phone
Dentist ____________________________________________________________________________________________ Name Address Phone
If I cannot be contacted, or the child’s physician, I understand that Ascension Lutheran Preschool will call the nearest physician/paramedics, call an ambulance and/or have the child taken to an emergency facility if deemed necessary. Any expenses incurred as a result of the above will be born by the child’s family.
Signature_________________________________________________________ Date______
LIABILITY RELEASE
I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of Ascension Lutheran Preschool as deemed age appropriate.
I recognize that accidents do happen and thus agree to hold free of liability Ascension Lutheran Preschool staff if such an incident occurs except in the case of proven negligence.
Signature___________________________________________________________Date__________
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