Matthews Presbyterian Church

ChildDevelopmentCenter

P.O. Box 1860Matthews, NC 28106

704-847-5564 ext.21

2013-2014

Registration

___Currently Enrolled ___ Sibling ___ Church Member ___ Alumni ___ New Enrollment

Child’s Name______Nickname ______

Age on August 31st______years _____ months Sex ______Birthday ______

Name of Parent(s) or Guardian(s) with whom child lives ______

Mailing Address ______

City/State/Zip Code______

Home Phone ______E-Mail______

Siblings Enrolled name______age______and name______age______

Registering For:

_____Infants (3 months – 11 months)M/W $175 per month

_____Toddlers (12 –23 months)M/W or T/Th$175 per month

_____Toddlers (12-23 months) M/W/F or T/Th/F$210 per month

_____Two Year Olds T/Th$185 per month

_____Two Year OldsT/Th/F$220 per month

_____Three Year Olds9a.m. – 1p.m.M/W/F$230 per month

_____Four Year Olds9a.m. – 1p.m.M-Th$260 per month

_____ Four Year Olds 9a.m. – 1p.m.M-F$305 per month

Registration fee: Matthews Presbyterian Church Members $50 per child

Non-MPC church members $75

* All registration fees are non-refundable.

*September 1st is the date that your child must meet the age requirements for each age group.

*To enroll in the 3 year old classroom your child must be potty trained.

*All children other than infants are required to carry a MPC- CDC tote bag to and from school. If you do not already have a tote bag, please add $10 to your registration fee.

*Your first tuition payment is due by May 15, 2013. This will serve as your tuition for May 2014.Failure to make this payment by May 15, 2013 will result in you giving up your spot in the program. This payment is only refundable if you provide the CDC with 30 days written notice.

Parent Signature ______Date______

Date Enrolled ______

Non-Refundable Registration Fee Received ______

Tote Bag Fee______

Check Number ______

(over)

*Tuition is due in nine equal payments. The first payment serves as tuition for May 2014 and is due by May 15, 2013. If registration occurs after May 15th, it is due at the time of enrollment. If the first payment is not received by May 15th, your spot will be forfeited for the 2013-2014 school year. The first payment is refundable with a written 30 day notification of withdrawal. The following schedule outlines the due dates for the payments.

Payment #1: Due on or before May 15, 2013
Payment #2: Due on or before September 12, 2013 (due date is different due to school start date)
Payment #3: Due on or before October 7, 2013
Payment #4: Due on or before November 7, 2013
Payment #5: Due on or before December 7, 2013
Payment #6: Due on or before January 7, 2014
Payment #7: Due on or before February 7, 2014
Payment #8: Due on or before March 7, 2014
Payment #9: Due on or before April 7, 2014

*It would be greatly appreciated to have completed forms turned in by May 25th. They must be on file with the center by the first day of school. Thank You

Registration application
Emergency information form
Family information form
Physician’s statement/immunization form
Photo permission form
Parent Handbook Acknowledgement Checklist (in the back of the Parent Handbook)

Note: The center must have a copy of the child’s completed physician’s statement/immunization record.The child’s physician must sign the copy. If parents contact their child’s doctor, a copy can usually be provided within a few days, but each office has its own policies and systems. It is the parent’s responsibility to provide this information to the school.

Family Information

You can help us plan for your child’s needs, understand concerns, and responses, and support and encourage your child if you provide the following information. The information will remain confidential; we hope you will update it when needed. If you feel uncomfortable answering any questions, please feel free to write that.

Name of Parent 1 ______

HomeAddress______County ______

Phone (H) ______(W)______(C)______

Name of Parent 2______

HomeAddress______County ______

Phone (H) ______(W) ______(C) ______

Marital status of parents:

□ Married □ Living together □ Separated □ Divorced □ Widowed

If divorced, please describe custody and visitation agreement for your child.

Others in your household:

Sisters, give names and ages

Brothers, give names and ages

Others, give names, ages, and relationship to child

Other significant persons in your child’s life (stepfamilies, grandparents, babysitters, etc.) Please give ages of children listed.

Names Relationship to child

______

Does your child have a pet?

Kind: Name:

______

Have there been births, deaths, adoptions, or other changes in the family structure which affected your child? If so, please describe briefly what happened and the effect on your child.

Tell us how you explained this event to the child.

What opportunities does your child have to play with other children?

□ neighborhood □ Sunday school/church □ cousins/other family

□ nursery school or other classroom experience □ other ______

What are your child’s favorite play activities?

Do you consider your child hard or easily managed?

What methods of discipline have you found most effective?

What fears does your child have?

How are they expressed?

What do you and your child enjoy doing together?

What trips, vacations, or other family experiences are remembered with the most pleasure?

What special happening is your child apt to tell us about?

How much television does your child watch a day?

What are his/hers favorite programs?

How much sleep does your child require daily?

Does he/she nap regularly? ______Usual bedtime: ______

Does your child use a pacifier?

Does your child have a comfort item?

What communicable diseases has your child had? Indicate date and age.

Chicken Pox ______Scarlet Fever ______

Mumps ______Measles ______

Impetigo ______Conjunctivitis (pink eye)______

Does your child have frequent occurrences of the following?

Colds ______Coughs ______

Tonsillitis ______High Fever ______

Upset Stomach ______Convulsions ______

Seizures ______

Has your child had a serious illness, surgery, or hospital stay?

If so, please describe condition and child’s reaction?

Does your child have any medical, physical, mental or social conditions that have been recently treated or are currently being treated by a professional?

If yes, does your child have an IFSP or IEP?

Are bowel and bladder functions regular and under control?

Has your child had a vision test?

Results:

Has your child had a hearing test?

Results:

Has your child had a regular dental checkup?

Any dental problems?

Is your child taking any regular medication?

If so, describe.

Does your child have allergies?

If so, to what substances?

How are allergies manifested? (hay fever, upset stomach, other)

Does your child have any dietary restrictions?

If so, describe

Is this restriction due to an allergy, family preference, medical need, other?

Describe your child’s overall health.

Please give any additional information you think might be important for us to have.

What hopes and expectations do you have for your child from our program?

Matthews Presbyterian Church

Child Development Center

P.O. Box 1860

Matthews, NC 28106

From time to time photographs of our preschool program will be made for educational as well as publicity purposes. These pictures will be representative of the enriching experiences offered to your child during the school year. The majority of the photos taken will be for classroom use, i.e. memory books, etc.

______I do

______I do not give permission for my child/children

______

(please list all children enrolled) to be photographed for use in educational, nonprofit publications/presentations intended to further the cause of Matthews Presbyterian Church Child Development Center. This permission is applicable for current, as well as, future projects. If we plan to use your child’s photo in publicity or advertising, we will advise you ahead of time. No child’s name will be printed in such uses.

You are encouraged to ask questions about anything that is unclear to you. You have the option of withdrawing your permission at any time.

______

Parent Signature

______

Date

Matthews Presbyterian Church CDC Emergency Information and Release Form

Child’s Full Name______Name Called______Class______

Known Allergies______DOB______/______/______

Parent (1) Name______Address______

Parent (1) Phone (h)______(c)______(w)______

Parent (2) Name______Address______

Parent (2) Phone (h)______(c)______(w)______

Email Address______

Emergency Names and Phone Numbers

Name______Relationship______Phone______

Medical Emergency Names and Phone Numbers

Physician Name______Phone______

Dentist Name______Phone______

Other Name______Phone______

Names and Phone Numbers of persons to whom we may release your child

Name______Relationship______Phone______

The undersigned, as parent or guardian of the child, hereby agrees that Matthews Presbyterian Church Child Development Center, its directors, employees, and agents are authorized to provide first aid or emergency medical care to my child and/or to obtain such emergency medical care for my child as may appear reasonably necessary in my absence including emergency transportation to a hospital. I agree to be financially responsible for any and all medical expenses or costs that are incurred in treating my child for illness or injury when said illness or injury arises while my child is on the premises of or in the custody of MatthewsPresbyterianChurchChildDevelopmentCenter.

The undersigned agrees to indemnify and hold MatthewsPresbyterianChurchChildDevelopmentCenter, its directors, employees, and agents and Matthews Presbyterian Church, its employees and agents harmless against any and all claims arising as a result of my child attending and/or participating in the activities of MatthewsPresbyterianChurchChildDevelopmentCenter.

I CERTIFY THAT I HAVE READ THE ABOVE AGREEMENT AND AGREE TO THE TERMS THEREOF.

Parent or Guardian Signature: ______Date______

Matthew Presbyterian Church

Child Development Center

P.O. Box 1860

Matthews, NC 28106

Physician’s Statement/Immunization Record

Child’s Name ______Birth Date ______

Address ______Telephone ______

Parent’s Names ______

Doctor’s Name / Address / Phone Number ______

______

Insurance Information ______

Hospital Preference ______

If the child has a specific health problem, please list anything special that the center needs to be aware of: ______

______

Please list any allergies that this child has: ______

The following immunizations have been administered and are up to date for this child’s age.

Required Immunizations:Please fill in the date that each was administered.

Hepatitis B #1 ______DTap #1 ______HibTITER #1 ______

Hepatitis B #2 ______DTap #2 ______HibTITER #2 ______

Hepatitis B #3 ______DTap #3 ______HibTITER #3 ______

Hepatitis B #4 ______DTap #4 ______HibTITER #4 ______

DTap #5 ______

IPV #1 ______MMR #1 ______

IPV #2 ______MMR #2 ______

IPV #3 ______

Optional Immunizations:

PREVNAR #1 ______Varivax ______

PREVNAR #2 ______

PREVNAR #3 ______

PREVNAR #4 ______

Date of last physical examination: ______Summary and findings from last physical examination: ______

Date ______Doctor’s Signature ______