PRBC Preschool Registration

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Please use this form to register your child for preschool.
Please Note: The preschool does not provide for scheduled or individual days.

Untitled Title

Statement of Understanding *

I have read the PRBC Preschool Parent's Policies and Procedures.

Policies and Procedures.pdf.

Yes

Required

Registration Year *

2024 Summer Program

2024/2025 School Year

Required

Date to be enrolled

YYYY

Age Group *

Toddlers - (15-23 months)Must be 15 months by September 1, 2023 & walking

K-2 Must be 2 by September 1, 2023

K-3 Must be 3 by September 1, 2023 Must be fully potty trained

K-4 Must be 4 by September 1, 2023

***$80 registration fee MUST BE PAID to secure their spot!!***

** $25 registration fee MUST BE PAID to secure their spot for summer!! **

Required

Child's Information

First Name *

Last Name *

Child's Preferred Name

Child's Date of Birth *

YYYY

Child's Current Age *

15-23 months

2 years

3 years

4 years

Required

Child's Sex *

Female

Male

Child's Residence/Home Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Home Phone *

Please identify the person(s) who have legal custody of the child, include relationship. *

Documentation may be required in special cases of joint custody, court decrees, etc.

The Child's parents are *

Not Married, Share Custody

Not Married, Sole Custody

Married

Separated, Share Custody

Separated, Sole Custody

Divorced, Share Custody

Divorced, Sole Custody

Other:

Father's Information

First Name

Last Name

Father's Spouse (If other than Child's Mother)

Father's Place of Employment

Father's Cell Number

Father's Work Number

Father's E-mail

Mother's Information

First Name

Last Name

Mother's Spouse (If other than Child's Father)

Mother's Place of Employment

Mother's Cell Number

Mother's Work Number

Mother's E-mail

Do the parents and children all live in the same home?

Yes

Yes, but parents are not legally married

Does your child have previous preschool or child care experience? If YES, please describe below.

Please list at least three (3) people we can contact if a parent cannot be located in the case of an emergency. These individuals will also be authorized to pick up your child.

Please keep all the contact numbers updated. This is very important in case we need to reach you in an emergency.

Emergency Contact 1

First Name *

Last Name *

Phone Number *

Relationship to child *

Pick-up *

This person has permission to pick up my child from preschool without a note

This person has permission to pickup my child from preschool with a note

Required

Emergency Contact 2

First Name *

Last Name *

Phone Number *

Relationship to child *

Pick-Up *

This person has permission to pick up my child from preschool without a note

This person has permission to pickup my child from preschool with a note

Required

Emergency Contact 3

First Name *

Last Name *

Phone Number *

Relationship to child *

Pick-Up *

This person has permission to pick up my child from preschool without a note

This person has permission to pickup my child from preschool with a note

Required

Is there anyone who cannot pick up your child? *

Yes

Required

If YES, please list the name(s)

Does your child have siblings or live with other children? *

Yes

Required

Please list the names and ages of other children in the home.

General Information

Does your child have any specific fears?

Does your child make friends easily?

What are your child's favorite activities?

What are your child's favorite TV shows?

Does your child attend Sunday School?

Yes

Other:

Clear selection

Where does your family attend church?

Permissions

We will occasionally take pictures of our preschool children during their activities.

May we have permission to photograph your child? (For making crafts with the child's picture.) *

Yes

Required

May we have permission to use your child's picture in church publications for the purpose of promotions? (We will sometimes put pictures on the preschool Facebook page. This allows parents see some of the fun the children are having.) *

Yes

Required

Medical Information/Permission for Emergency Medical Treatment

At or before orientation, I will be required to complete a medical information sheet for my child which will include insurance information and preferences. In the event of a medical emergency, when I cannot be reached, I hereby give permission for Pleasant Ridge Baptist Church Preschool to arrange emergency transportation to the hospital and for a licensed physician to provide medical care for my child. Any qualified person providing such required medical attention, treatment, or services may accept this consent as if given by me in person. I agree to assume responsibility for payment of all medical costs incurred, including that of emergency transportation to the hospital. I understand that Pleasant Ridge Baptist Church Preschool will make every effort to contact me as soon as possible.

I have read and agree with the above statement on medical treatment. *

Yes, I understand and give my consent.

Required

Please list any allergies along with a description of the reaction and treatment for the reaction.

Does the child require use of an inhaler *

Yes

Required

Please list any medications or drugs taken regularly by the child. (If none, put "none") *

Please describe the general health of your child. *

Signature (Please type your full name) *

Submit

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