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Little Rams Preschool Registration 2017-2018
Registration Date:______
Child’s Name:
Last: ______First: ______Middle: ______Preferred Name: ______
Home Address: ______City: ______State: ______Zip: ______
Home Phone: ______Religion: ______
Male _____ Female _____ Date of Birth: ______Age on September 1, 2017: ______
Father’s Name: ______Employer______Occupation: ______
Home Address: ______Home Phone: ______Religion: ______
Work Phone: ______Cell Phone: ______Email: ______
Mother’s Name: ______Employer ______Occupation: ______
Home Address: ______Home Phone: ______Maiden Name: ______
Work Phone: ______Cell Phone: ______Email: ______Religion: ______
Child Lives With: Both Parents ____ Mom ____ Dad ____ Guardian ____
Parent’s Marital Status: Married ____ Divorced ____ Separated ____ Widowed ____ Single _____
Names and ages of siblings: ______
Elementary School your child will attend: ______
I have students enrolled at Good Shepherd School Yes___ No ___
Good Shepherd Parishioner? Yes ____ No ____
List emergency contacts or anyone else authorized to pick your child up from preschool
NamePhone#Relationship
1.______
2. ______
3. ______
4. ______
How did you hear about Little Rams Preschool? Friend ______Church Bulletin ______Mailer ______
School Newsletter ______Other (please list) ______
Check your child’s predominant ethnic background
Race and Ethnicity: (Note: Both Part A and Part B of the questionmust be answered.)Part A: / Is this student Hispanic/Latino? (Choose only one)
No, not Hispanic/Latino
Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central
American, or other Spanish culture or origin, regardless of race.)
The above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your student’s race to be.
Part B: / What is the student’s race?(Choose one or more)
American Indian or Alaska Native (A person having origins in any of the original peoples of
North and South American (including Central America), and who maintains tribal affiliation or
community attachment.)
Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.)
Black or African American (A person having origins in any of the black racial groups of Africa.)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.)
Language Spoken at Home:
Does your child have any of the following? Please explain.
Medical Conditions ______
Allergies ______
Behavioral Issues ______
Special Needs ______
Does your child have developmental delays or difficulties with any of the following? Please explain.
Speech ______
Walking ______
Toileting ______
Eating ______
Please Choose One
______3 Year OldProgram - $125 Enrollment Fee (Must be 3 by September 1st)
$75 August tuition due August 1st/$170 Monthly Tuition due Sept. 1st – May 1st
Tuesday and Thursday mornings from 8:15 – 11:00 AM
______4 Year Old Program - $125 Enrollment Fee (Must be 4 by September 1st)
$90 August tuition due August 1st/$198 Monthly Tuition due Sept. 1st – May 1st
Monday, Wednesday and Friday mornings from 8:15 – 11:00 AM
______Pre-K Program - $125 Enrollment Fee (Must be 4 by September 1st)
$100 Aug. tuition due August 1st/$218 Monthly Tuition due Sept. 1st – May 1st
Monday – Thursday afternoons from 12:15 – 3:00 PM
Tuition Options
_____Monthly Payments are due each month starting on August 1st and due on the 1st of each month thereafter.
_____One Annual Payment Due on August 1st in the amount of:
3 Year Old Program - $1,605
4 year Old - $1,872
Pre-K - $2,062
Parent/Guardian Initial
_____I understand that tuition is to be paid in full by the 1st of each month, that I must give a 30 day notice to withdraw my child from the program and that tuition and fees are non-refundable. A $10 Late Fee will be accessed if tuition is not paid by the 10th of the month. A $15 processing fee will be charged for all returned checks.
_____I understand that if my child is placed on a waiting list and Good Shepherd is unable to place my child in a class, my Enrollment Fee will be returned. I understand that if my child is placed in a class and I choose not to enroll my child, my fee will not be returned.
______
Please print child’s name
______
Parent/Guardian Signature Date
______
For Office Use Only: Date Received ______Time:______Received by: ______
Enrollment Fee received ______Birth Certificate Received ______