St. Mary’s Early Childhood Center & Preschool

216 Belmont Rd.

Grand Forks, ND 58201

701-775-7067

Registration Requirements:

  1. Complete Application
  2. Child Information
  3. Admission Forms (3 pages)
  4. Weekly Schedule & Tuition Agreement (2 pages)
  5. Service Contract
  6. Parent’s Statement on Health of Child
  7. Child Information Sheet from the ND Department of Human Services
  8. Field Trip Permission Form (Parents will be notified when a field trip will be scheduled)
  9. Notify Now Contract Form (School Announcements such as unscheduled closings, weather related announcements, etc.)
  10. Photo Permission Release Form
  11. Pre-Authorized Automated Debit Release Form (2 pages)
  12. Provide Copy of Current Immunization Records
  13. Provide Copy of Birth Certificate
  14. $30 non-refundableRegistrationFee (September 1st Registration Fee will be $40.00)
  15. This fee is due annually

St. Mary’s Early Childhood Center & Preschool

Weekly Schedule and Tuition Agreement

Child’s Name:______

Child’s Birthdate:______

Please select type of care needed

  • Full-Day Care: Your child may attend at any time during our normal business hours

(7:15 a.m. – 6:00 p.m.).

M – F

MTWThF

  • Part-Day Care: Your child may attend for up to 5 hours/day. These hours must be scheduled in advance to ensure adequate staffing. Care extending beyond the scheduled 5 hours will be billed at the drop-in rate of $6/hour.

M – F

MTWThF

Please list scheduled attendance hours:______

______

______

PRICING SHEET IS LOCATED IN LEFT SIDE POCKET OF PACKET

Page 1

  • After-school Care:Additional full/part day rates will apply for all school in-service days and holidays

M – F@$55/week

MTWThF@$12/day

Additional drop-in hours may be added, as space allows, at a rate of $6/hour.

Multiple Child Discount

10% discount on each additional each from the same family.

Tuition Agreement

I agree to enroll my child at St. Mary’s Early Childhood Center & Preschoolfor the indicated schedule and agree to pay the corresponding daily/hourly tuition rate beginning (date)______.

I understand that payment is due in advance of care and agree to pay the monthly tuition on or before the first day of the month that care is provided.

Parent Signature______Date______

Parent Signature______Date______

Pages 2

St. Mary’s Early Childhood Center & Preschool

Admission Forms

Parent/Guardian Information

Mother/Guardian

Name:______Social Security # ______

Home Address______

______

Home Phone:______Cell Phone:______

Place of Employment:______Work Phone:______

Address:______

Father/Guardian

Name:______Social Security # ______

Home Address______

______

Home Phone:______Cell Phone:______

Place of Employment:______Work Phone:______

Address:______

In the event that only one parent has custody of this child, please state which parent. Note: We must have a copy of a court ordered custody agreement on file to withhold a child from a non-custodial parent.

Custody:______

Signature:______Date:______

Page 1

Admission Form (Cont.)

Child Information

Child’s Preferred Name______

Does your child have siblings? YesNoIf yes, how many?______

What year do you anticipate your child will start kindergarten? ______

Does your child still take an afternoon nap? Yes No

Has your child previously attended child care? Yes No

How was the experience?______

______

______

Are there any areas that you anticipate your child may have difficulty? ______

______

______

Does your child have any special interests or hobbies? ______

______

______

What would you like your child to gain by attending St. Mary’s Project Kids & Tots?______

______

______

Recognizing that every child is an individual, does your child have any special needs or medical conditions/allergies that we should be aware of? ______

______

______

Does your child need help in any of the following areas? (circle all that apply)

DressingUndressingWashing Hands Toileting Eating

OTHER: ______

______

Admission Form (Cont.)

Discipline

Parent/Guardian Statement on Discipline

St. Mary’s Early Childhood Center & Preschool understands that, at times, some form of discipline may be necessary for my child(ren). I, therefore, give my permission for St. Mary’s Early Childhood & Preschool, from whom I am receiving services, to use a non-severe discipline (please see parent handbook for guidance methods used). I have found the most effective method of guidance with my child to be:

______

______

______

______

Authorization to Release Child

Unless otherwise authorized by you in writing, no one but you or your spouse may pick up your child(ren) from St. Mary’s Early Childhood & Preschool. List below any others you wish to authorize for this purpose:

______

______

______

______

Page 2

Admission Form (Cont.)

Emergency Information

In case of an emergency and parents cannot be reached, who should be contacted?

Name:______

Home Address:______

Relationship to child:______Phone #______

If Medical Care is Necessary, Call:

Doctor Name:______Phone #______

Address______

Hospital______Phone#______

Address______

Please list any allergies, medications or medical concerns that we should be aware of:_____

______

______

______

I hereby authorize St. Mary’s Early Childhood Center & Preschoolto secure emergency medical treatment for my child under the following conditions:

  1. An emergency or unanticipated condition necessitates action for the preservation of life or health of the child
  2. Reasonable attempts to contact me have failed

Print Name:______

Signature:______Date:______

Page 3

St. Mary’s Early Childhood Center & Preschool

Service Contract

By signing this contract, I/we are agreeing to the following:

  1. I have received, read, understand and agree to accept the terms in the Parent Handbook as a condition of enrollment.
  2. I understand that to be enrolled, the child’s shot record and birth certificate must accompany the application.
  3. I understand that to be enrolled, the $30.00 registration fee must accompany the application. This fee is non-refundable.
  4. I agree to pay the monthly tuition on or before the first day of the week that care is provided. In the event that the tuition is not paid on time, I/we agree to pay a $5/day late fee (including weekends).
  5. I agree to provide a written two week notice upon termination of care and agree to pay for two weeks of care should we terminate without prior notice.

Parent Signature______Date______

Parent Signature______Date______

St. Mary’s Early Childhood Center & Preschool

(Field Trip Form to go on neighborhood walks and to the local park)

Child’s Name______

Address______

Home #______

Mother/Guardian Name:______Work #______Cell # ______

Father/Guardian Name:______Work # ______Cell # ______

Two emergency contacts who may assume responsibility for your child if you cannot be reached:

Name______Phone # ______

Name______Phone # ______

My child has permission to leave St. Mary’s Project Kids & Tots (on foot) for the purpose of attending field trips.

Parent Signature:______Date: ______

You will be notified in advance if transportation will be utilized for any field trips.

Please list any allergies or medical conditions:______

______

______

I hereby authorize St. Mary’s Project Kids & Tots to secure emergency medical treatment for my child under the following conditions:

  1. An emergency or unanticipated condition necessitates action for the preservation of life or health of the child
  2. Reasonable attempts to contact me have failed

Print Name:______

Signature:______Date:______

Notify Now Contact Form

St. Mary’s Project Kids and Tots will post weather related closures/delays and other important messages on WDAZ. We typically follow the same winter storm schedule as the Grand Forks Public School system. We will also be using the Notify Now system to send out mass text and e-mail messages to let you know of our closings or delays.

Child(ren)’s Name(s):______

Parent Names(s):______

Cell #s:______

E-mail:______

Product Permission Form

St. Mary’s Early Childhood Center & Preschool will supply hand lotion, sunscreen, bug repellant and hand-sanitizer should a child run out of their own. (Please label all personal supplies.). We will keep this put away to be used as needed. I give permission for the following products to be applied to my child (name)______:

We will notify you and fill in the brand name of the products.

Lotion:______

Chap stick:______

Sunscreen:______

Bug Repellant:______

Parent Signature:______Date:______

Dear Families,

For purposes of advertisement as well as to provide valuable information to prospective and incoming families, St. Mary’s maintains a website at like to occasionally update the site with photos that reflect our evolving curriculum and environments.

Please complete the bottom portion of this form to let us know if we may use your child’s image for this purpose. Please note: we will never post your child’s name or any other identifying markers with the photographs.

Photo Release Form

  • Yes, I give permission for images of my child,______to be used for advertising purposes on the St. Mary’s Early Childhood and Preschool website through St. Mary’s Church.
  • Yes, I give permission for my child’s photo’s to be used in classroom newsletters and bulletin boards.

No, I do not give permission for images of my child, ______to be used for advertising purposes on the St. Mary’s Project Kids & Tots website.

Signed______Date______

Pre-authorized Debits Customer Authorization Form

St. Mary’s Project Kids is pleased to offer you a new way to make your preschool/daycare payments using pre-authorized debits. Now you can have your payment made automatically each week and you don’t have to change your present banking relationship to take advantage of this service.

  • No check writing with associated charges
  • Control over funds is guaranteed (via Regulation E)
  • Easy to sign up and easy to cancel

To take advantage of pre-authorized debits, simply complete the form as follows:

  • Check whether your payment will be deducted from your checking or savings account
  • Fill in your name, financial institute and location and date
  • Attach a voided check for verification of all the financial institution information. If you are unable to attach a voided check, please provide your account number.
  • Sign form

Pre-authorized debits are safe, convenient, and easy. To take advantage of this service, please complete the following information and return it along with your application packet.

YOU MUST COMPLETE THE ATTACHED FORM AND SUPPLY A VOIDED CHECK EVEN IF YOU DO NOT SIGN UP FOR AUTOMATED DEBITS.

In the event that your account becomes more than 2 weeks delinquent, this form authorizes us to automatically deduct the past due tuition as well as all associated late fees.

Page 1

Pre-authorized Debits Customer Authorization Form

Please print the following:

Name:______

Address:______

Financial Institution:______

Branch:______

Address:______

Signature:______Date:______

Bank Routing Number (9 digits):______

Account Number:______

Please select one of the following options.

  1. I do not wish to sign-up for pre-authorized, automated debits at this time. However, in the event that my tuition fees become delinquent by more than two weeks, I authorize St. Mary’s Church and the financial institute listed above to make a one-time deduction from my account in the total amount past due along with all associated late fees.

Signature:______Date:______

  1. I authorize St. Mary’s Church and the financial institute listed above to initiate electronic debit entries, and if necessary, credit entries and adjustments for any debit entries in error to my

( ) checking account( ) savings account

I understand this payment will be withdrawn weekly on Monday (if this falls on a holiday, transaction will occur the following business day).

I authorize a weekly deduction in the amount of $______

This authority will remain in effect until I have canceled it in writing.

Signature:______Date:______