Please Check the Class in Which You Wish to Enroll

St. Mark Preschool Registration Form

2018-2019

Student’s Name______

Address______Zip______

Phone______Birthdate______

E-mail address______

Please check the class in which you wish to enroll.

____3-Year-Old Class T-Th (8:30-11:30 a.m.) $120.00 per month. Maximum enrollment 15 students.

___Option to stay for lunch (11:30-12:25 p.m.) $135.00 per month.

____4-Year-Old Class M-W-F(8:30-11:30 a.m.) $145.00 per month. Maximum enrollment 18 students.

____Option to stay for lunch (11:30-12:25 p.m.) $165.00 per month.

____Pre-K-5 Class M-T-W-Th-F (8:30-11:30 a.m.) $220.00 per month. Maximum enrollment 12.

____Option to stay for lunch (11:30-12:25 p.m.) $250.00 per month.

Fees: A $70 non-refundable registration fee is due with this form to secure the child’s spot in the class.

Is child right-handed or left-handed______

Please list any allergies, medical concerns, or other information we need to know about your child:
______

______

Father’s name______Mother’s name______

Occupation______Occupation______

Work phone______Work phone______

Cell______Cell______

Marital status: _____Married ___Divorced ____ Single ____Separated

Names and ages of brothers and sisters: ______

Present place of active church membership______

Name of Pastor or priest______

Has your child been baptized? ______Date of baptism______

Persons to whom child may be released by preschool staff:

Name______Phone______

Emergency information:

Please provide the names of the following who could be contacted in the case of an emergency when parents can not be reached.

Neighbor______Phone______

Sitter______Phone______

Relative______Phone______

Doctor______Phone______

Hospital______Phone______

Due to inclement weather, sudden illness, etc., who would we be able to contact for immediate pickup?

Name______Phone______

To assist us with our recruitment efforts, may we ask how you heard about St. Mark Lutheran Preschool?

______

______Yes, I give my permission to use photos or videos of my child in the St. Mark Spirit and on the St. Mark Lutheran Preschool FB page taken during the current school year by St. Mark Lutheran Preschool.

______No, such permission is not granted.

Signature of Parent Date

If I can’t be reached and my child needs medical treatment, I give the staff of St. Mark Preschool my permission to seek such treatment. I understand they will continue to try to reach me.

Signature of Parent Date

I hereby give St. Mark Preschool permission to transport my child for school field trips on a bus contracted through First Student. I understand that participation of field trips is voluntary.

Signature of Parent Date