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: _______________________
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Are there any fears of which we should be aware? If so, describe the usual reaction:
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What opportunities has your child had to play with other children?
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What are your child’s favorite toys?
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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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