Precious Pebbles Preschool

PRECIOUS PEBBLES PRESCHOOL

Christ Our Rock Lutheran Church & Preschool

3040 Stonehedge Dr. NE

Rochester, MN 55906

(507) 252-5088

www.Christourrock.org

REGISTRATION FORM

CHILD’S NAME: ______DOB ___/___/______

Last First MI

CURRENT ADDRESS: ______

Street Apt. #

______

City State Zip Code

CHILD’S HOME PHONE NUMBER: (_____) ______Check (√) if you can be reached at this

number during preschool hours.

FATHER’S/GUARDIAN’S NAME: ______

FATHER’S/GUARDIAN’S HOME NUMBER: (_____) ______CELL PHONE #: (_____) ______

FATHER’S/GUARDIAN’S WORK NUMBER: (_____) ______

FATHER’S/GUARDIAN’S PLACE OF EMPLOYMENT: ______

MOTHER’S/GUARDIAN’S NAME: ______

MOTHER’S/GUARDIAN’S HOME NUMBER: (_____) ______CELL PHONE #: (_____) ______

MOTHER’S/GUARDIAN’S WORK NUMBER: (_____) ______

MOTHER’S/GUARDIAN’S PLACE OF EMPLOYMENT: ______

OTHER NUMBERS: (_____) ______(_____) ______(_____) ______

FAMILY E-MAIL ADDRESS: ______

CHURCH CURRENTLY ATTENDING: ______

AUTHORIZED PERSONS TO TAKE CHILD FROM PRESCHOOL:

NAME: RELATIONSHIP: PHONE NUMBER:

______(_____) ______

______(_____) ______

______(_____) ______

______(_____) ______

PERSONS TO CONTACT IN CASE OF AN EMERGENCY, IF YOU ARE UNABLE TO BE REACHED:

NAME: CITY, STATE: PHONE NUMBER:

______

______

______

ENROLLMENT:

I’m enrolling my child in the Precious Pebbles Preschool Program for:

______Tuesday & Thursday 9:00 AM – 11:30 AM

______Tuesday & Thursday 12:30 PM – 3:00 PM

______Tuesday & Thursday (All Day) 9:00 AM – 3:00 PM

______Monday, Wednesday, & Friday - 9:00 AM – 11:30 AM

______Monday, Wednesday, & Friday – 12:30 PM – 3:00 PM

______Monday, Wednesday, & Friday (All Day) - 9:00 AM – 3:00 PM

______Monday thru Friday (All Day) - 9:00 AM – 3:00 PM

______I would be interested in using the Precious Pebbles Preschool Wrap-Around Care

I hereby give authorization to Christ Our Rock Lutheran Church & Precious Pebbles Preschool staff to administer Syrup of Ipecac according to Minnesota Rules, Part 9503.0140.

______

Signature

I hereby authorize Christ Our Rock Lutheran Church & Precious Pebbles Preschool staff to seek emergency medical treatment in the event that the parent(s)/guardian(s) cannot be reached or is delayed.

______

Signature

DESCRIBE ANY DIETARY AND/OR MEDICAL NEEDS OF YOUR CHILD THAT YOU ARE AWARE OF:

(Please attach sheet, if further instructions are needed.) ______

______

DESCRIBE ANY SPECIAL NEEDS AND/OR CONCERNS OF YOUR CHILD THAT YOU ARE AWARE OF:

(Please attach sheet, if further instructions are needed.) ______

______

The information I have provided to the Precious Pebbles Preschool Program is accurate to the best of my knowledge. I understand that, for my child to attend the first class, I need to provide the Precious Pebbles Preschool Program with the attached health care summary, immunization record, and “Emergency Authorization Form.” I will also notify Precious Pebbles Preschool of any changes to the information provided.

______

Signature Date

EMERGENCY AUTHORIZATION

NAME OF CHILD’S PHYSICIAN: ______PHONE #: ______

ADDRESS: ______

______

If unavailable, another licensed physician may treat my child: ______Yes ______No

PREFERRED HOSPITAL: ______PHONE #: ______

ADDRESS: ______

NAME OF PARENT’S INSURANCE CO.: ______POLICY #: ______

NAME OF CHILD’S DENTIST: ______PHONE #: ______

ADDRESS: ______

In case of a medical emergency, we hereby authorize any and all necessary tests, procedures,

and/or treatment for our son/daughter

______at ______

Patient’s Name (please print) Name of Hospital

when we are not available. We authorize PRECIOUS PEBBLES PRESCHOOL STAFF

Name of Day Care Provider

to seek such medical care.

Dated: ______Signed: ______