REGISTRATION
FORM
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Here for Word Format X
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:
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EMERGENCY 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
In the event that neither I, nor my Emergency Contacts can be reached, or if
the emergency is
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.)
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BACKGROUND 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?