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:______________________

Email: ___________________________________________  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 or SWNS. 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. Your call will be returned at the earliest possible time. Messages are checked weekly during summer vacation and holidays. (The church secretary has forms in her office. She is normally in from 8:00AM-Noon on weekdays year round.

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.)

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________
 

 

 

 

 

 
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