Registration Form 2017-18

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