Application Form – Grace Preschool – 3’s 2017-2018

343 Grand Ave., Loves Park, Illinois61111 Phone: 815-282-6114

Harlem Dist.______

Rockford Dist.______Birthdate: ______

Other Dist.______Month/Day/Year

Child’s Name______( ) Boy ( ) Girl

(First) (Last)(Nickname)

Parent’s Names

(Mom) ______(Dad) ______

(First) (Last) (First) (Last)

Marital Status: ( ) Married ( ) Divorced ( ) Single ( ) Separated

E-Mail Address ______

Phone (Home) ______

Mom’s Address ______Dad’s Address (if different) ____________

______

Mom’s Cell Phone______Dad’s Cell Phone ______

Employer (Mom) ______(Dad) ______Address :(Mom’s) ______(Dad’s) ______

______

Work phone (Mom) ______(Dad) ______

Working hours: ______

Physician ______Preferred hospital ______

In case your child becomes ill or injured and needs immediate care, and you or your physician cannot be reached, your child will be taken to the nearest clinic.

Child release: (Only those listed below (other than Mom or Dad) will be allowed to pick up your child.)

Name______Name ______

Address______Address ______

Phone (home) ______Phone (home) ______

Phone (cell) ______Phone (cell) ______

Related how? ______Related how? ______

A written permission slipmust be sent to the teacherbefore anyone other than the above can pick up your child.

Emergency Contacts:

Name ______Name ______

Address______Address______

Phone (home) ______Phone (home) ______

Phone (cell) ______Phone (cell) ______

*************************************************************************************

FOR OFFICE USE ONLY

___Physical Received ___DCFS Booklet Signed ___Discipline Booklet Signed ___Card for Treasurer ____Birth Certificate

DATE OF PHYSICAL: ______DATE REGISTERED______

REGISTRATION FEES: ______

DATE PAYMENT RECEIVED: ______

AMOUNT PAID: ______CHECK #: ______

DATE ADMITTED: ______DATE DISMISSED: ______

(PLEASE COMPLETE BACK OF FORM)

Class preference

(Please keep in mind that while we are giving you a preference, we cannot guarantee this class until after all applications are in to determine number and class balance)

A child must bethree by September 1stof the current year inorder to enroll in athree-year-old preschool class. Please ask about possible exceptions.

Please indicate your first (1) and second (2) choice: ( ) TTH A.M.8:45 to 11:30

( ) TTH A.M.8:30 to 11:15

( ) MWF A.M.8:45 to 11:30

( ) TTH P.M.12:15 to 3:00

Names and ages of other children in your family______

______

Did they attend Grace Preschool? ( ) Yes ( ) No

Does your family attend Church? ______If so, where? ______

If not, are you interested in more information about Grace Lutheran Church? ______

How did you find out about our school? ( ) Family ( ) Friends ( ) Flier ( ) Poster( ) YardSign ( ) Newspaper ( ) Sunday School( ) Website ( ) Postcard( ) Referred by______

Does your child have any of the following? (Explain)

Allergies______

Speech problems______

Health problems______

Group experience______

Your signature will authorize the following:

  1. As part of the curriculum, we learn about God through Chapel and Bible Stories, and prayer is a regular part of our day.
  2. Field trips will be taken and permission slips are required.
  3. Trips within walking distance are permitted without permission slips.
  4. Pictures will be taken in the spring and possibly for special events. Class pictures and candid photos are posted on our website and Facebook. All photos may be used for publicity purposes.
  5. If necessary, a qualified staff member may administer first aid to your child.
  6. In an emergency, parents will be contacted and/or medical services obtained immediately.
  7. Information pertaining to the admission, progress, health, or discharge of an individual child shall be confidential, unless the parents have granted written permission for disclosure.
  8. Grace Preschool follows all licensing regulations through DCFS.

Parent’s Signature______Date Signed ______

PAYMENTS

$100 Registration Fee (Non-refundable)

$100 Monthly Tuition – (2 days per week) September through May

$150 Monthly Tuition – (3 days per week) September through May

$4 per month technology fee for SmartCare- online billing/check in system