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ST. Paul Evangelical Lutheran Church of Bethpage |
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REGISTRATION FORM
St. Paul Lutheran Church, Little Gospel Lights Pre-School (516) 933-4446 PLEASE RETURN THIS FORM WITH YOUR ENROLLMENT & PAYMENT
Class Preference: 3YR AM 3YR PM 4YR AM 4YR PM Enrichment 2 “BYE” 2 (Meeting Dates) They Came By 2 (Meeting Date)
Child’s First Name: Last Name: SEX: M F
Date of Birth: Home Telephone #:
Street Number: Street Name:
City: State: Zip:
Current Church Affiliation:
Mother’s Name: Father’s Name:
Mother’s Cell Phone #: Father’s Cell Phone #:
Mother’s Work Phone #: Father’s Work Phone #:
Name Release: I give my permission to have my child’s name, parents’ names, address, and phone number on a class list to be distributed to parents of children in the class. This will allow children to get together for play dates, birthday parties, etc.
Signature: _______________________________________ Date:
Photo Release: I give permission for my child’s photograph (names withheld) to be placed in local newspapers and on the St. Paul website whenever Little Gospel Lights may publish an event which has taken place in the school, such as class parties, trips, etc.
Signature: _______________________________________ Date:
Speech Screening: I give permission for my child to be screened by a professional Speech Therapist if available.
Signature: _______________________________________ Date: Page BreakEMERGENCY CONTACT
St. Paul Lutheran Church Little Gospel Lights Pre-School
If both Parents/Guardians are not available, in the event of an emergency call: (This is also an authorization to release my child to the adults listed below). Please inform the person (s) listed below that their name appears as an emergency contact for your child.
IMPORTANT: THIS IS OUR ONLY MEANS OF COMMUNICATING WITH YOU IN AN EMERGENCY DURING THE HOURS THAT THE PRE-SCHOOL IS IN SESSION. BE AS SPECIFIC AND DETAILED AS POSSIBLE.
Name: Phone: Relationship:
Name: Phone: Relationship:
Name: Phone: Relationship:
Physician: Phone #:
Has your child had any serious illness, injury or operation during the past year? Yes No
Does your child receive any special services (Speech, O/T, P/T)? Yes No
Does your child have any vision problems? Yes No
Does your child have any hearing problems? Yes No
Does/Has your child receive (d) any medication on a regular basis? Yes No
Does your child have any allergies? Yes No
Does your child have any activity restrictions? (i.e., playground, etc.)? Yes No
CONSENT TO MEDICAL TREATMENT
deemed extreme, the judgment of Little Gospel Lights Staff shall prevail.
Parent/Guardian Signature: ______________________________ Date:
(Please use the reverse side after printing for any additional information.)
Page BreakBACKGROUND INFORMATION
St. Paul Lutheran Church Little Gospel Lights Pre-School
Please answer the questions below. This will enable your child’s teacher and the staff of Little Gospel Lights to have a better understanding of your preschooler.
1. Has your child been in the care of adults other than his/her parents? Yes No
2. Has your child attended any other preschool, day care, organized group setting? Yes No
3. Do you have any concerns about your child’s development? (Physical, intellectual, emotional, social?) Yes No
4. What would you like your child to gain from his/her Christian Pre-school experience?
5. Is your child toilet trained? Yes No
6. Is there any additional information that may be helpful?
7. Please note your occupation (s) past and present: (Sometimes we ask a parent to share information about his/her occupation with our pre-school students – e.g. fireman, police officer, pizzeria owner, etc.)
8. Would you be interested in serving as a Class Parent? Yes No
9. How did you hear about Little Gospel Lights? |
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