Little Blessings Preschool Enrollment 2023-2024

Child Information

Name

Address

Birthdate

Phone

This number will be used in case of an emergency.

Please list any medical concerns/allergies

Please list any rescue medication

Parent Information

First Parent Name

First parent home phone (if different from above)

First parent cell

This address will receive a confirmation email

Place of employment

Work number

Second parent name

Second parent cell

Second parent email

Place of employment

Work number

Madison Programs

Year round: Indicate desired start date

School Year: Starts September 5, 2023 or later. Indicate Desired Start Date:

Verona Programs

Please choose from the following: Ravens 3-5 years Wednesday, Thursday, Friday 8:30-11:30 am Whales 3-4 years Monday, Tuesday, 8:30-11:30 a.m. Extended Day Tuesday 11:30 a.m.-3:00 p.m. Extended Day Wednesday 11:30 a.m.-3:00 p.m. Extended Day Thursday 11:30 a.m.-3:00 p.m. 4K Private Pay Only 8:30 a.m.-11:30 a.m.

Consent

I consent to the use of photography and/or video of my child for classroom use and congregational publicity.

Little Blessings Preschool Prints an annual Student Directory based on the information contained in this form. It is distributed in-house to currently enrolled families. Please indicate below if you wish to be included in the directory.

Directory consent Yes

I consent that my child has permission to participate in all children's ministry activities, under supervision. Good Shepherd Lutheran Church and its personnel will not be held responsible for accidents or personal injury arising there from.*By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this registration form.

Yes

Signature (type name)

Today's date

Registration & Material Fee

This fee is non-refundable and is not applied to tuition. To enroll your child return this form and the fee to the school.

Payment $125.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Little Blessings Preschool Enrollment 2023-2024

Description

Please Fix the Following