Preston Meadow Preschool Application for Enrollment Page 1 of 4

School Year 20___ - 20___ Child Information

Last Name First Name Goes By Date of Birth Age as of 9/1/20___ Sex (M/F)

Home Address Apt City State Zip Code Home Phone #

Parent/Guardian Information List the best telephone numbers where parents/guardians may be reached while child is in care.

Mother Parent Step-Parent Guardian Father Parent Step-Parent Guardian Last Name First Name Last Name First Name

Home Address (if different from child) Home Address (if different from child)

Cell # Home # Cell # Home #

E-Mail address E-Mail address

Employer Name Work Phone # Employer Name Work Phone #

Pick Up List (other than parent/guardian) I hereby authorize Preston Meadow Preschool to allow my child to leave ONLY with the following persons. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

Name(s) Cell # DL/ID# & State Issued by

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION In the event I cannot be reached to make arrangements for emergency medical care, I authorize Preston Meadow Preschool to secure any and all necessary emergency medical care for my child.

Name of Physician:

Address: Phone #:

Name of Emergency Hospital: Address: Phone #:

Insurance Company: Policy Number: Phone#:

I, ______________________________________________ give consent for the facility to secure any and all necessary emergency medical care for my child.

_____________________________________________ Signature of Parent or Guardian

Office Use Only

Date of Admission: ________________________________ PMLC Church Members _______

Date of Withdrawal: ________________________________

Class Enrolled: ________________________________

Days Enrolled: ________________________________

Enrolled in: AM ______________ PM _____________ (12/6/2018 Revised, C. Stelzl)

Preston Meadow Preschool Application for Enrollment Page 2 of 4

EMERGENCY CONTACT (other than parents) Give the name, address and phone number of person to call if parents or guardian cannot be reached.

Name: Address: Phone#: Relationship

List any special problems that your child may have, such as allergies (that we should post), special nutritional needs, existing illnesses, previous illnesses, injuries and hospitalizations during the past 12 months. Include medications prescribed for continuous, long term use, and any other information which staff should be aware of: none

My child’s allergies are (check one): Mild Moderate Severe Children with severe allergies or existing medical conditions must meet with office personnel and teacher to discuss the procedure to be followed in case of any emergency.

Authorizations and Acknowledgements CHECK ALL THAT APPLY:

1) WATER ACTIVITIES: I hereby Give Do not give – my consent for my child to participate in water activities. Sprinkler play Splashing/wading pools Water table play

2) CURRENTLY ENROLLED CHILDREN: My child attends the Preston Meadow Preschool program and his/her immunization record is on file at the school and all immunizations and tuberculosis test (if required) are current.

CHILDREN NEW TO THE WEEKDAY PROGRAM: I have provided the Preston Meadow Preschool with a current immunization record and tuberculosis test (if required).

3) PRESTON MEADOW PRESCHOOL POLICIES: I have downloaded a copy of the program parent handbook from http://pmlc.org/preschool including those for discipline and guidance. I have read, understand and agree to abide by the policies as stated in this document.

4) IMAGE USE: I hereby Give Do not give – my consent for my child to have his/her PHOTOGRAPH taken and used on bulletin boards, class booklets, school publications and school website.

5) SCHOOL DIRECTORY: I hereby Give Do not give – my consent for my child’s name and address to be printed in the CLASS ROSTER and or a SCHOOL DIRECTORY.

Snacks and Meals I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE: AM Snack PM Snack (Lunch is provided by parents)

Helpful Information Schools attended previously Years attended

Referrals If someone referred you to our program, please state their name(s):

Over-the-Counter Product Release Form Occasionally, your child may require first aid during the day. For these occasions, we maintain a limited supply of first aid products. Your signature below authorizes the office staff to administer any of items below, if needed.

Printed Name: Signature:

Benadryl Spray (insect Spray)

Antibiotic Ointment

Mylacon Gas Drops

Teething Gels

Caladryl (itching)

Diaper Ointments/ Cream

Saline Nose Spray /Drops

Other:

Preston Meadow Preschool Application for Enrollment Page 3 of 4

Financial Agreement

By signing the Parent-School Financial Agreement, I recognize that tuition and fees must be current in order to ensure continuous enrollment. I understand tuition is due on the 1st of the month and past due by the 10th. Payments received after the 10th will incur a $25 Late Fee. If payment in full is not received by the end of the month, student will not be allowed to attend Preston Meadow Preschool until balance of tuition AND all fees are paid in full. At that time, the student will be allowed back in school, if space is available. If your child must be absent from our program for an undetermined amount of time, tuition must be paid in full for the time your child is away in order to hold their space in the classroom.

Signature – Parent or Legal Guardian Print Name Date

Registration Fee (NON-REFUNDABLE) Registration forms are not processed until a $100 Registration Fee is attached or processed through auto-pay.

Please make checks payable to: PRESTON MEADOW PRESCHOOL Amount Paid:

$ Date Paid: Payment Method

Cash Check #_________ Credit Card ACH

I give permission for PRESTON MEADOW PRESCHOOL to process my account through ACH draft/Credit Card auto-pay.

Supply Fee (NON-REFUNDABLE) Infants: Due in May $100 / 2 day program $125 / 3 and 5 day programs

Toddlers – PreK: Due in May

$75 / 2 day program $100 / 3 and 5 day programs

Tuition is based on a full school year budget. Rates are calculated based on the choice of program days. August is a full months tuition with no tuition due in June.

Please enroll my child in the following: Every effort will be made to enroll in your first choice. Should this not

be possible, you will be contacted and be placed on a waiting list. Enrollment into a specific class has no

guarantee regarding who the teacher or other children will be.

Extended AM Care 7:00a – 9:00a (First choice) M T W Th F

(Second choice) M T W Th F

Core Program 9:00a – 2:00p (Select One)

Two Day Program T/Th

Three Day Program M/W/F

Five Day Program M/T/W/Th/F

Extended PM Care 2:00p – 5:30p (First choice) M T W Th F

(Second choice) M T W Th F

(Extended care will be offered as long as space is available. Staff/Child ratios must be kept at all times.)

Preston Meadow Preschool Application for Enrollment Page 4 of 4

Parent Acknowledgement - Admissions Agreement

I understand that all paperwork and forms given to describe important information regarding Preston Meadow Preschool policies. If at any time I have questions regarding these policies, I should consult a member of the management team. I agree to comply with all policies that are in place and acknowledge that I have received the following information.

I have read and will comply with the policies set forth in the Parent Handbook at www.pmlc.org/preschool. I further agree to comply with these policies. All forms and requirements must be completed before my child will be admitted to Preston Meadow Preschool.

My relationship with Preston Meadow Preschool is voluntarily entered into and is subject to termination by me or the preschool with or without cause, at any time that either the preschool or I believe such action is appropriate at will. Such termination shall be subject to all policies relating to termination of services. A two week written and / or verbal notice when withdrawing from the program is required. Without notice the family is responsible for full month tuition payment. I understand and agree that Preston Meadow Preschool reserves the right to terminate the enrollment agreement for the following reasons:

End of the school year

Failure to resolve any delinquency in tuition

Our program is unable to meet the needs of your child

Our program determines it is not in the best interest of the program and other children enrolled to have my child in attendance

Our program determines my child or I have been unable to adjust to the program

Information was falsely stated on the Registration form or other required documents

Parents have not complied with the Preston Meadow Preschool

I am responsible for informing office personnel concerning special health, physical, social, or emotional needs my child may have. This includes allergies, pre-existing illnesses and injuries and all hospitalizations as well as any treatment that is being administered to my child.

A copy of the State of Texas Minimum Standards Rules for Child-Care Centers is available for review along with the center’s most recent Licensing Inspection Report. I acknowledge that I have received (via website), read and understand the policies contained in the parent handbook.

___________________________________________________ _______________________________ Parent Signature Date