First United Methodist Church

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.)

__________________________________________________________________

__________________________________________________________________

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