You are on page 1of 4

www.cpchurchmedina.

org
Registration Form
Date: __________________________
Child’s Full Name: __________________________________Nickname: ____________________________
Birth date: _________________ Gender: ________ Soc. Sec. #
Mother/Guardian Father/Guardian
Name: ________________________________ Name: __________________________________
Address: ______________________________ Address: ________________________________
City________________________Zi________ City___________________________Zi________
D!#________________________State______ D!#___________________________State_____
Soc. Sec. # ____ Soc. Sec. # _____
"ome #hone: _____________________ _____ "ome #hone: ____________________________
$ork #hone: __________________________ $ork #hone: _____________________________
Cell #hone: ___________________________ Cell #hone: ______________________________
%e&t 'essa(e) *circle+ ,es No %e&t 'essa(e) *circle+ ,es No
-mail: ________________________________ -mail: ___________________________________
#arents are:
___'arried. ___Coha/itin(. ___Di0orced. ___Searated. ___$ido1ed. ___Sin(le
#arent2Guardian 1ith le(al custody ________________________________________________
(It is helpful to furnish a copy of the divorce decree or custody agreement which will be kept
in your child's file and all information will be confidential. Without a copy of the official
papers, we may not be able to prevent your child from leaving with his/her non-custodial
parent.
Office Use: Start Date: _________Immunization records: _____on file: _____complete ____incomplete. Upon
approval by CSP, $! non"refundable re#istration fee is due $to be included in first %"&ee' payment( _____ paid.
Initialed by: _______________
Emergency Contacts (other than parents) & People Permitted to Pick Up Child:
345 Cum/erland Street. 'edina. %N 67688
963:;37:43<=
Cum/erland Street #reschool >e(istration Form
Family #hysician: #hone:
Name: ________________________________ #hone Num/er*s+:______________________
Name: ________________________________ #hone Num/er*s+:______________________
Name: ________________________________ #hone Num/er*s+:______________________
id Code: _____________________ *Secret 1ord /et1een arent ? child @or identi@ication and ick u+
Aller(ies 2 Secial Needs or Anstructions 2 'edications: *use /ack i@ necessary+__________________________
__________________________________________________________________________________________
Bther "ousehold 'em/ers: *names. a(es. relationshis+: ___________________________________________
__________________________________________________________________________________________
Parent/Guardian !greement
A here/y (i0e my consent to ha0e my child treated /y a hysician @or medical or sur(ical care should an
emer(ency arise. A understand that e0ery e@@ort 1ill /e made to contact me. or one o@ the names listed a/o0e. /e@ore
such action is taken. *initial: _______+
A a(ree to ay the tuition due. in ad0ance and on a @our:1eek /asis. @or the time my child is enrolled. A
understand that late @ees 1ill /e added @or any tuition not aid on time. A understand that A may 1ithdra1 at any time /y
noti@yin( the school o@@ice one 1eek in ad0ance. in 1ritin(. and all tuition and @ees are aya/le uon other a/sences. A
a(ree to ay any and all @ees associated in any 1ay 1ith the collection o@ any unaid tuition and2or late @ees. *initial ____+
A here/y (i0e my consent to ha0e my child hoto(rahed and his2her icture laced on dislay at the reschool.
on the school 1e/site. reroduced and rinted in our school annual. and used in ro(ram DCDs. A also (i0e ermission @or
my child’s ictures to /e used @or marketin( and teacher trainin( uroses. *initial: _______+
A ha0e recei0ed a coy o@ the Deartment o@ -ducation DChildcare Aro0al >eEuirementsF @or reschools. and a
coy o@ the #reschool #arent #olicies and Child A/use #olicy statement and a(ree to a/ide /y those olicies. A also a(ree
to con@er 1ith the school @irst i@ A ha0e any Euestions or ro/lems. *initial: _______+
A certi@y that in@ormation ro0ided is correct.
______________________________________________ ________________________
#arent or Guardian’s Si(nature Date
345 Cum/erland Street. 'edina. %ennessee 67688
963:;37:43<=
Cum/erland Street #reschool >e(istration Form
"e#elopmental $ealth $istory
Child’s Name2Nickname _________ Date o@ Birth
Physical Health
3+ !ist any ast health ro/lems your child has had:
=+ !ist any current health ro/lems:
6+ Does your child ha0e any en0ironmental aller(ies) *A@ so. to 1hat
5+ Does your child take any medications re(ularly) *A@ so. 1hat)+
8+ "as your child /een hositaliGed recently) *A@ so. @or 1hat)+
;+ Does your child ha0e any reoccurrin( health ro/lems such as: asthma dia/etes seiGures
ear aches hemohilia other
9+ Does your child ha0e any ro/lems 1ith any o@ the @ollo1in() Seech 1alkin( runnin(
seein( hearin( usin( their hands *such as 1ith uGGles or small items)+
#lease e&lain any marked a/o0e on item se0en:

Daily Living
3. Does your child ha0e any @ood aller(ies)
=. Does your child like to slee 1ith a @a0orite item. such as a stu@@ed animal. /lanket. etc.)
6. Does your child need hel 1hen chan(in( clothes)
5. As your child accustomed to restin( a@ter lunch) A@ so. @or 1hat len(th o@ time)
Social Relationships
3. As your child accustomed to layin( alone or 1ith other children)
=. Does your child ha0e a @a0orite toy)
6+ Descri/e your child’s lay 1ith others: A((ressi0e Shy #lays -asily
5+ As your child @ri(htened /y any o@ the @ollo1in(: Animals______ !oud noises the dark
Storms Anythin( else)
8. $ho does most o@ the discilinin( at home)
As there any other in@ormation you 1ish to share that 1ould assist us)

345 Cum/erland Street. 'edina. %ennessee 67688
963:;37:43<=
Cum/erland Street #reschool >e(istration Form

#arent2Guardian si(nature
345 Cum/erland Street. 'edina. %ennessee 67688
963:;37:43<=