TLC PRESCHOOL
REGISTRATION FORM—2017-18
Phone: (360) 421-0800
Date:______
Please answer all questions. All information is confidential.
Child’s Name______Preferred Name used at school______
Last First Middle
Home Address of Child:______Telephone:( ____ )______
City:______ZipCode_
E-mail address______
Birthdate: Month______Day______Year______
Place of Birth:______Sex:______M______F
City State
Father’s Name______Mother’s Name______
Father’s Occupation:______Business Phone: (_____)______
Name & Address of Employment:______
Father’s Working Hours:______
Mother’s Occupation:______Business Phone: (_____)______
Name & Address of Employment (If other than home):
______
Mother’s Working Hours:______
Mother’s Cell Phone: (____)______Father’s Cell Phone: (_____)______
EMERGENCY INFORMATION
Child’s Physician:______Phone: (_____)______
______
Physical Handicaps:______
ALERGIES:______
LOCAL EMERGENCY PHONE NUMBER (other than parents at home or work)
Name:______Relationship______
Address:______Phone: (_____)______
RELIGIOUS INFORMATION
Church Affiliation (i.e.) Lutheran, Catholic, etc.) Mother:______
Father:______
Name of Congregation Mother Attends:______
Name of Congregation Father Attends: ______
Our Family Attendance at Church is: Regular______Occasional______Don’t Attend______
Child Attends Sunday School: ( )Yes ( )No If Yes, Where?______
SOCIAL DEVELOPMENT
Has your child had previous preschool experience?______
Where?______
Does your child have neighborhood playmates? ______How many?______
Sex and Age: ______
How well does he/she get alone with the other children?______
BEHAVIOR (circle word or words that apply)
Calm excitable easily angered whining crying happy cheerful stubborn cooperative
quiet Independent active fights often gives in easily want own way temper tantrums
What behavior do you consider the most difficult to deal with?______
If there is any other information that you feel would be helpful to us in working with your child, please indicate here: ______
HOME ENVIRONMENT
Status of Parents: Married______Divorced ______Separated ______Single ______
All children in family and Ages
1.______2.______3. ______4.______
Any adults, other than parents, in the home? ______
What are their roles in the life of your child?______
Left or right handed?______Favorite play acitivity ?______
Favorite toy?______
Special interests such as trips, bugs, plants, etc. ______
How did you learn about our Preschool?______
SESSION DESIRED:
Toddler
9:00-10-30am ______am Tuesday, Thursday
3 year olds -
9:00-11:15am ______Monday, Tuesday, Thursday (3-day)
9:30-11:45am ______Monday, Wednesday, Friday (3-day)
9:00-11:15am ______Monday, Tuesday, Thursday, Friday (4-day)
9:00-2:30pm ______Tuesday, Wednesday, Thursday (3-day)
4/5 year olds (Pre-K)
9:00-11:30am ______Tuesday, Wednesday, Thursday (3-day)
9:00-11:30am ______Tuesday, Wednesday, Thursday & Friday (4-day)
9:00-11:30am ______Monday-Friday (5-day)
9:00-2:30pm ______Tuesday, Wednesday, Thursday (3-day)
11:30-2:30 ______Tuesday, Wednesday, Thursday (3-day)
This schedule is due to change due to enrollment
Mail to: Trinity Lutheran Church
Attn: Preschool School Use Only
301 S. 18th Street Date Amount
Mount Vernon, WA. 98274 Registration Fee Received: ______/______
Registration Fee: $75.00 1st child, $40.00 for additional children
Tuition Fees: Toddler-2-day $75.00 a month
3 day class $145.00 a month
4 day class $175.00 a month
5 day class $205.00 a month
3 day AM/PM classes $235.00 a month
5 day AM/3 day PM classes $315.00 a month
Confirmation on Class schedule will be mailed the 1st part of July.
Tuition is due by the 10th of the month. If tuition is not paid and arrangements are not made by the 15th of the month, we will have no choice but to dis-enroll your child until you make your account current.
______
Parent/Guardian Signature Date