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God’s Garden Preschool-Heyworth Christian Church

Heyworth, IL 61745            Phone 309-473-2771

Email: victoria@heyworthcc.com

 

 

PLEASE MARK YOUR PREFERENCE:

o   PreK - 3 Day   Child is 4 by September 1st

o   PreK – 4 Day   Child is 4 by September 1st

o   Preschool – 2 Day   Child is 3 by September 1st

You will be notified about which session your child will attend

 

 

Student’s First Name:_____________________________  Home Phone Number:____________________________

 

Child’s Name to use & write in class: _______________________________________________________________

 

Student’s Middle Name:___________________________  Mother’s Name:_________________________________

 

Student’s Last Name:_____________________________   Mother’s Place of Work:__________________________

 

Male____    Female____                                                       Mother’s Work Phone:____________________________                                                                                

                                                                                   

Student’s Birthday:_______________________________  Mother’s Cell Phone:_____________________________

 

Address:_______________________________________  Mother’s Email:__________________________________

 

______________________________________________   Father’s Name:__________________________________

 

______________________________________________   Father’s Place of Work:___________________________

 

Mailing Address (if different)______________________   Father’s Work Phone:_____________________________

 

______________________________________________   Father’s Cell Phone:______________________________

 

Home Email:___________________________________   Father’s Email:__________________________________

 

Names of Brothers and Sisters and their Ages

 

________________________________________   ______           __________________________________________   ______

 

________________________________________   ______           __________________________________________   ______

 

What type of discipline is most successful for you child?________________________________________________

 

______________________________________________________________________________________________

 

 

What do you hope your child gains from attending preschool?____________________________________________

 

______________________________________________________________________________________________

 

1.

 

MEDICAL INFORMATION

 

List any specific health problems your child has:________________________________________________________________

 

_______________________________________________________________________________________________________

 

 

Name of Family Physician:______________________________________________Phone:_____________________________

 

Please check if your child has had:  Measles _____   Mumps ____   Chicken Pox _____   Scarlet Fever _____

Tonsillectomy _____   Multiple Nose Bleeds _____  Premature Birth _____   Serious Accidents _____

(Please list accidents) _____________________________________________________________________________________

 

Please list Allergies you child has:___________________________________________________________________________

 

What type of Allergy treatment is used?_______________________________________________________________________

 

Is your child presently taking any kind of medication?  Yes_____    No_____

If yes, please explain:_____________________________________________________________________________________

 

Does your child have handicaps, disabilities, or special needs?  Yes_____    No_____

If yes, please explain:_____________________________________________________________________________________

 

 

EMERGENCY MEDICAL CARE PLAN

 

If the teacher feels that emergency medical care is needed and is unable to reach the parent/guardian or other persons listed on this form, then the Heyworth Ambulance Service will be called to transport the child.  The cost of the ambulance will be billed to the parent/guardian.

 

If a child is exempt from medical care on religious grounds, the parent/legal guardian is required to state that in writing and to submit that name and phone number of a certified practitioner who can be called in case of a medical emergency.

 

I/We have read the above Medical Plan and understand it.

 

___________________________________________________    __________________________________________________

   (Parent/Guardian Signature)                                                                 (Parent/Guardian Signature)

 

Relationship to child if other than parent signing:________________________________________________________________

 

 

EMERGENCY MEDICAL CARE

 

This authorizes God’s Garden, Heyworth Christian Church Preschool to secure EMERGENCY medical care, including transportation by the Heyworth Ambulance Service, for my child when I/We cannot immediately be reached at the time of the emergency.

I/We will be responsible for the emergency medical charges, including ambulance fees, upon receipt of the statement.

 

PREFERRED DOCTOR:__________________________  Preferred Hospital/Clinic___________________________________

 

______________________________________________      _______________________________________________________

    (Parent/Guardian Signature)                                                      (Parent/Guardian Signature)

 

Relationship to child if other than parent signing:________________________________________________________________

 

 

2.

EMERGENCY INFORMATION

 

The following people have permission to pick up my/our child from the preschool: (other than parent)

 

Name:______________________________   Phone:____________________________

 

Name:______________________________   Phone:____________________________

 

Name:______________________________   Phone:____________________________

 

Is your child with a Daycare Provider?    Yes___   No___  If yes, please provide name:

 

Daycare Provider’s Name:______________________________  Phone:___________________

 

If your child becomes sick during preschool and a parent cannot be reached, we will contact someone on the above list.

 

 

RELIGIOUS INSTRUCTION

 

I/We give permission for God’s Garden, Heyworth Christian Church Preschool to give my/our child religious instruction of a basic nature, including Bible stories, Scripture verses, and moral training as part of the overall preschool curriculum.

 

_________________________________________________   _____________________________________________

  (Parent/Guardian Signature)                                                                      (Parent/Guardian Signature)

 

Relationship to child if other than parent signing:________________________________________________________

 

 

PHOTOGRAPHS

 

I/We give permission for my/our child to be photographed with God’s Garden, Heyworth Christian Church Preschool, to be used  for the purpose of publicity  or news articles in local newspapers, etc.                                                                              

 

___________________________________________________   ___________________________________________

       (Parent/Guardian Signature)                                                                             (Parent/Guardian Signature)

Relationship to child if other than parent signing:____________________________________________________________________

 

 

ADDRESS AND PHONE NUMBER RELEASE

 

I/We give permission for God’s Garden, Heyworth Christian Church Preschool, to give my name or my child’s name, address, and phone number to other parents of God’s Garden, Heyworth Christian Church Preschool.

 

____________________________________________________   __________________________________________

   (Parent/Guardian Signature)                                                                         (Parent/Guardian Signature)

Relationship to child if other than parent signing:___________________________________________________________________

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

TRIPS AND EXCURSIONS

 

I/We authorize God’s Garden, Heyworth Christian Church Preschool, to take my/our child on walking trips, special excursions, and to nearby public park facilities.  I/We also authorize the child to ride as a passenger in a vehicle owned or leased by the above-named facility, or in an approved privately-owned vehicle.  I/We understand that all such trips are under the supervision of the above-named facility and that health and safety precautions are taken at all times. 

 

_____________________________________________________   _____________________________________________

   (Parent/Guardian Signature)                                                                    (Parent/Guardian Signature)

Relationship to child if other than parent signing:_______________________________________________________________________

 

TUITION PAYMENT AGREEMENT

 

I/We the parents of _____________________________________agree to pay the set monthly tuition  according to the number of days child attends God’s Garden, Heyworth Christian Church Preschool.  I/We understand that the first payment of tuition will be due at parent orientation and every month after that on the first school day with the last payment being in May.

I/We agree to pay a late fee of $5.00 for any monthly payments made after the 10th of each month unless other arrangements are made.

I/We understand that delinquency in payment after one month may result in mu/our child being discharged from the preschool.

 

_____________________________________________________    ______________________________________________

  (Parent/Guardian Signature)                                                                                 (Parent/Guardian Signature)

Relationship to child if other than parent signing:_________________________________________________________________________

 

Date:___________________________________________

 

 

 

HANDBOOK STATEMENT

 

I/We understand that we are responsible for obtaining a copy of the Preschool Handbook and abiding by its contents.  This Handbook will be available at Open House prior to the beginning of the school year.

 

_____________________________________________________   _______________________________________________        (Parent/Guardian Signature)                                                                                 (Parent/Guardian Signature)

Relationship to child if other than parent signing:_________________________________________________________________________

 

Date:______________________________________________     

 

 

 

4.

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