Preschool Registration

Unique ID

1. Student Information

Student Name(Required)

First Middle Last

Does your child prefer to be called by a nickname?

Yes

Preferred Nickname(Required)

Which name would you like your child to learn to write/print?(Required)

Given Name

Nickname

Both

Date of Birth(Required)

Month

Day

Year

Current Age

Age on August 1

Class Choice(Required)

This field is automatically selected based on your child's date of birth. However, you may change it if you've been instructed to.

3-4yr / Tue,Thur / 8:30A-11A

4-5yr / Mon,Wed,Fri / 8:30A-11A

Pre-K / Mon-Fri / 8:30A-11:30A

NOTICE: A child must be 5 years old ON OR BEFORE August 1 to begin Kindergarten. Therefore, the same cutoff date "on or before August 1" is used for placement in the appropriate age preschool class.

2. Contact Information

Who does the child reside with?(Required)

Both Parents

Mother

Father

Guardian/Other

Residence Address(Required)

Street Address Address Line 2 City ZIP Code

Mother's Information

Mother's Name(Required)

First Last

Mother's Phone Number(Required)

Mother's Text Messaging Consent

Can we text you?

By checking this box, you hereby give your consent to receive text messages related to Calvary Lutheran Church and Preschool. You understand that your consent is voluntary, and you can opt-out at any time by contacting Calvary Lutheran Church and Preschool. Standard messaging and data rates may apply.

Mother's Email Address(Required)

Mother's Occupation(Required)

Mother's Work Phone(Required)

Mother's Address(Required)

Street Address Address Line 2 City ZIP Code

Father's Information

Father's Name(Required)

First Last

Father's Phone Number(Required)

Father's Text Messaging Consent

Can we text you?

Father's Email Address(Required)

Father's Occupation(Required)

Father's Work Phone(Required)

Father's Address(Required)

Street Address Address Line 2 City ZIP Code

Guardian/Other Information

Guardian/Other Name(Required)

First Last

Guardian/Other's Phone Number(Required)

Guardian/Other's Text Messaging Consent

Can we text you?

Guardian/Other's Email Address(Required)

Guardian/Other's Occupation(Required)

Guardian/Other's Work Phone(Required)

3. General Information

Are there other children in the immediate family?(Required)

Yes

Names and Ages of other children in the household.(Required)

Name

Age

Religious Affiliation(Required)

Baptist

Lutheran

Pentecostal

Catholic

Methodist

Episcopal

Non-Denominational

Other

Do you and your child currently attend church?(Required)

Yes

4. Enrollment Information

How did you hear about Calvary Lutheran Preschool?(Required)

Newspaper Ad

Ad - Web/Other

Calvary's Preschool Sign

Realtor

Recommended by Family or Friend

Other

Who Referred You?(Required)

5. Medical Disclosures

NOTE: At Calvary, our doors are always open with a warm embrace for all children, especially those navigating a range of disabilities and health challenges. We deeply value their presence and contributions. However, it's essential to understand that while we offer a loving environment, we currently don't have a certified nurse or specialized medical facilities on-site. If your child's disability or health condition might require instant medical intervention or specific equipment, you might want to consider alternatives such as a public preschool that's better equipped for such needs. We're here to support you in making the best decision for your child's well-being.

Is your child's immunizations up to date?(Required)

Yes

Not Sure

Does your child have any allergies?(Required)

Yes

Unknown

Allergies(Required)

Please list any and all allergies and be as descriptive as possible. Example: Allergy: What is the specific allergen? (e.g., peanuts, bee stings, latex), Description: Can you provide more details about the allergic reaction? (e.g., hives, difficulty breathing, anaphylaxis), Requires Immediate Treatment?: In the event of exposure, does the reaction require immediate intervention? (e.g., EpiPen, antihistamine), Severity: On a scale from 1-10, how severe is the typical reaction? (1 being mild and 10 being life-threatening), Frequency: How often does the reaction occur upon exposure?, Last Occurrence: When was the last time the child had an allergic reaction?, Medications: Are there any medications the child takes regularly for this allergy? If so, please list them., Doctor's Instructions: Are there specific instructions from the child's physician regarding the allergy that we should be aware of?

Allergy

Details

Does your child have any disabilities?(Required)

Yes

Unknown

Disabilities(Required)

Please list any and all disabilities and be as descriptive as possible. Example: Type of Disability: What is the specific nature of the disability? (e.g., Autism Spectrum Disorder, Cerebral Palsy, Down Syndrome, ADHD) Description: Can you provide more details about the disability and how it affects daily activities or learning? Accommodations Required: What specific accommodations or modifications does the child need to be successful in a learning environment? Medical Equipment: Does the child require any medical or adaptive equipment? (e.g., wheelchair, hearing aids, communication devices) Medications: Does the child take any medications related to the disability? If so, please list them and their schedules. Behavioral Concerns: Are there any behavioral manifestations related to the disability that we should be aware of? Therapies: Is the child undergoing any therapies or interventions? (e.g., physical therapy, speech therapy, occupational therapy) Emergency Protocols: Are there any emergency protocols or procedures we should follow related to the disability? Specialist Recommendations: Are there specific recommendations or instructions from specialists or therapists that would be beneficial for us to know? Preferred Communication Method: How does the child best communicate? (e.g., verbal, sign language, communication device) Other Important Information: Is there any other information about the child's disability that you feel is vital for us to know?

Disability

Details

Does your child have any health concerns?(Required)

Yes

Unknown

Health Concerns(Required)

Please list any and all health concerns and be as descriptive as possible. Example: Nature of Health Concern: What is the specific health concern? (e.g., asthma, diabetes, epilepsy) Description: Can you provide more details about the health concern and how it might manifest or affect the child's day? Frequency & Severity: How often do symptoms or episodes occur, and how severe are they typically? Medications: Is the child taking any medications related to the health concern? If so, please specify the medicine, dosage, and frequency. Medical Equipment: Does the child require any specific medical equipment or devices? (e.g., inhaler, insulin pump, seizure alarm) Emergency Protocols: Are there any immediate steps or protocols we should follow if a health episode occurs? Dietary Restrictions: Are there any food or drink restrictions related to the health concern? Physical Activity Limitations: Are there activities the child should avoid or modifications needed for physical activities? Signs to Monitor: What are early signs or symptoms we should be aware of indicating an impending health episode or exacerbation? Doctor's Recommendations: Are there specific recommendations or instructions from the child's physician regarding the health concern? Previous Hospitalizations: Has the child been hospitalized due to this health concern? If so, when was the last occurrence? Other Important Information: Is there any other pertinent information about the child's health concern that you believe is crucial for us to know?

Health Concern

Details

Does your child have any extreme fears?(Required)

Yes

Unknown

Extreme Fears(Required)

Please list any and all extreme fears and be as descriptive as possible. Example: Nature of Fear: What is the specific fear? (e.g., heights, dark spaces, certain animals) Description: Can you provide more details about the fear and how it manifests? What are the typical reactions or behaviors the child displays when confronted with the fear? Origin: If known, what is the origin or cause of this fear? Was there a specific incident or experience? Severity: On a scale from 1-10, how intense is the child's reaction to the fear (1 being mild discomfort and 10 being an extreme panic reaction)? Avoidance Measures: Are there specific environments, situations, or objects we should avoid to prevent triggering the fear? Coping Mechanisms: Are there techniques or strategies that help the child cope when confronted with the fear? (e.g., deep breathing, having a comfort item) Support Required: How can we best support the child if they are exposed to their fear or if they're feeling anxious about it? Therapies or Interventions: Is the child undergoing any therapy or intervention related to this fear? If so, what recommendations have been provided by professionals? Progress Over Time: Has the intensity or nature of the fear changed over time? Is it improving, worsening, or remaining stable? Other Related Concerns: Are there other fears or concerns related to this primary fear? Other Important Information: Is there any additional information about the child's extreme fear that you feel is vital for us to understand?

Extreme Fear

Details

Please call us with any changes in the information provided on this page. It is imperative that we remain updated on any changes in your child's health and well-being. All information provided will be kept confidential.

Parental/Guardian Consent and Liability Waiver for Participation(Required)

I, the individual named below, having full knowledge of my child's health status and any existing physical conditions, hereby absolve Calvary Lutheran Church and Preschool, as well as its employees and representatives, from any responsibility or liability that may arise due to unforeseen injury, illness, or harm my child may experience while participating in their activities. By signing, I acknowledge understanding the inherent risks associated with these activities and voluntarily choose to allow my child's involvement, relinquishing any future claims of negligence against the institution and its staff.

Online Document Submission and Communication Consent

I, the undersigned, acknowledge and consent to the following:

Submission of Documents Online(Required)

I hereby grant permission for the submission and transmission of documents and information through online platforms associated with Calvary Lutheran Church and Preschool. I understand the risks associated with online data transmission and agree that the institution is not liable for any unforeseen breaches or misuses beyond its control.

Accuracy of Information(Required)

I affirm that all the information and documents I have provided are accurate, complete, and true to the best of my knowledge. I take full responsibility for the veracity of the submitted details and understand that any misrepresentation may have consequences.

Consent to Contact(Required)

I grant Calvary Lutheran Church and Preschool the right to contact me through various communication channels, including but not limited to e-mail, phone, text message, and post. I understand that I can opt out of specific communication methods or update my contact preferences at any time by reaching out to the institution.

Registration Fee(Required)

Upon submitting my application to Calvary Lutheran Church and Preschool, I understand that I am required to pay a non-refundable registration fee of $25. This fee is essential for the processing and consideration of my application. I am aware that failure to pay this fee may result in my application being incomplete or not processed. By signing below, I confirm my understanding of this requirement and agree to fulfill this financial obligation as part of the application process.

Signature(Required)

By signing below, I confirm my understanding and agreement to the terms stated above.

Printed Name(Required)

First Last

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Contact Info

Preschool Registration

1. Student Information

2. Contact Information

Mother's Information

Father's Information

Guardian/Other Information

3. General Information

4. Enrollment Information

5. Medical Disclosures

Please call us with any changes in the information provided on this page. It is imperative that we remain updated on any changes in your child's health and well-being. All information provided will be kept confidential.

Online Document Submission and Communication Consent

Contact Info

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