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PAGE 1: (Please check appropriate class.)
_______ 2-Day Playgroup (2 years old by August 1)
_______ 2-Day 3 & 4 Year-Olds (3 years old by Aug.1)
_______ 3-Day Pre-K (4 years old by Aug. 1)
_______ 5-Day Pre-K (4 years old by Aug. 1)
_______ Pre-K Extended Hours 9 AM-1 PM (2 days) (Pre-K students only)
(Please also check above to indicate whether you want the 3 or 5 day option.)
Child’s Name: ___________________________________________ Male____ Female____
Home Address:_____________________________________ City:______________________
Zip Code: ______________________
Home Phone ( )______________________________ Birthdate:____/____/_________
Full name of father:______________________________________ Phone( )___________
Place of Employment:______________________________ Phone( )___________
Full name of mother:_____________________________________ Phone( )___________
Place of Employment:______________________________ Phone( )___________
Names and ages of brothers and sisters:
_____________________ _______________________ _____________________
Does the child live with both parents? Yes No If not, with whom? ______________________
Any medical problems or physical limitations: _________________________________________
Does your child have any food or other allergies? _______________________________________
Please list any drugs/medications presently being taken by the child: _______________________
______________________________________________________________________________
Are there any fears of which we should be aware? If so, describe the usual reaction:
________________________________________________________________________________
What opportunities has your child had to play with other children?
_________________________________________________________________________________
What are your child’s favorite toys?
__________________________________________________________________________________
PAGE 2:
I give my permission for the staff of Susanna Wesley Nursery School to administer CPR/ first aid/emergency procedures in case of illness or accident at school.
I further give permission and authorize the nursery school staff to obtain medical services, including but not limited to calling an ambulance and/or x-ray examination, anesthetic, surgical treatment or any hospital service, for the above-named student in the event said student suffers any illness or accident.
This medical consent is given in advance of treatment to encourage and authorize the school and employees and/or medical personnel to exercise their judgment in the best interest of my child.
It is understood that I will assume responsibility for necessary expenses as may be incurred in the foregoing.
Date:________________________ Signature:_______________________________________________
Name of Child’s Physician:__________________________________ Phone: ( )______________
In case of accident, notify:___________________________________Phone: ( )______________
(other than parents)
Or:____________________________________Phone: ( )______________
To finalize enrollment, return the form and a $50.00 NON-REFUNDABLE enrollment and materials fee to the following address:
Susanna Wesley Nursery School
601 Main Street
Mt. Vernon, IN 47620
Make checks payable to: Susanna Wesley Nursery School. As soon as enrollment forms and fees are received, your child is placed on a class roster. If you have any questions, please feel free to call (812)838-2835. Someone may be reached at the school between 8:30 and noon, Monday through Friday during the school year. If there is no answer, please leave a voicemail.
This child may be picked up by the following people:
(Please include; phone numbers, including area code, and relationship to the child. Please include Mom and/or Dad.)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
