Check One:             

Current Student                           _____                                                                                 Current Class Name:      

Sibling of a current student            _____                                                                         ______________________

Sibling of an alumni student           _____              701 Bennett Street

Church Member                           _____              Herndon, VA 20170                         

New                                          _____                  703-435-5688                                                                                  

____________________________________________________________________________________________________________

2008-2009 APPLICATION

Registration Fee: $60.00 ($20.00 for each additional child)

 

CHILD’S NAME: ____________________________________________________________________________

                                                            Last                                                      First                             

 

NAME TO BE USED AT PRESCHOOL, IF DIFFERENT FROM FIRST NAME_________________________

 

 

CHILD’S BIRTHDATE: _____________________________                                             SEX: ________________

 

 

INDICATE SESSIONS PREFERRED, IN ORDER OF PRIORITY: (1st, 2nd, 3rd)

 

Options for 4 and 5 year olds (must be 4 by Sept. 30, 2008):

 

M-F am _____                        Tu-F am _____            MWF am _____

 

Options for 3 year olds (must be 3 by Sept. 30, 2008):

 

MWF am _____          TuTh am _____           

 

Option for young 3’s (must be 3 by Dec. 31. 2008):

 

                        TuTh am _____

____________________________________________________________________________________________________________

PARENT’S INFORMATION: 


 

MOTHER                                                                 FATHER

 

NAME:                        __________________________________         ___________________________________

HOME PHONE: ________________________________           ___________________________________

CELL PHONE: __________________________________        ___________________________________

ADDRESS:      __________________________________         ___________________________________

CITY, ST., ZIP: __________________________________        ___________________________________

EMPLOYER:   __________________________________         ___________________________________

WORK PHONE: _________________________________        ___________________________________

EMAIL ADDRESS for Parent/School Communications: _____________________________________________

Does the child live with both parents? _________ If not, to which address should school forms be mailed? ___________

Is the child in the care of someone other than a parent during the day?    If YES, please complete:

Caregiver’s Name: _______________________________________   Phone Number(s): __________________________

 

(over)

 

Other members of your household:

Name                                                               Age (if a minor)                                                Relationship to Child

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

What language(s) are spoken at home? ______________ Please check if translation assistance is needed______

 

Child’s previous school or day care experience: ___________________________________________________

 

Does your child have any allergies?      YES____          NO____

If YES, please list his/her specific allergies: ______________________________________________________

__________________________________________________________________________________________

 

Medications taken to treat allergic reactions: _____________________________________________________

 

Please add any comments that may help us understand your child’s special needs: ________________________

__________________________________________________________________________________________

 

Names of all other people who are authorized to pick up your child: ___________________________________

__________________________________________________________________________________________

 

How did you learn about the Herndon Preschool? _________________________________________________

 

Would you like to receive the Herndon United Methodist Church newsletter?                Yes             No

 

By signing below I give permission for my child to participate in the Herndon United Methodist Church Preschool program. I understand that the first tuition installment is due on May 1, 2008 in order to hold my child’s place in the program. This payment will be applied as the final tuition payment for the 2008-2009 school year. If HUMC Preschool does not receive this payment by May 1, 2008, I understand that my child’s place in the program will be forfeited. This payment is refundable if HUMC Preschool receives written notice of my intent to withdraw my child from the program by July 15, 2008. The remaining eight installments are due and payable on the first of each month beginning September 1, 2008 with the last installment due April 1, 2009.

 

_____________________________________________                  _____________________________________________

Parent Signature                                                                                    Date of Application

 

*The $60.00 ($20.00 for each additional sibling) application fee must be attached in order for your application to be processed. The application fee is not refundable once a class placement has been made. Please make checks payable to HUMC Preschool.

_______________________________________________________________________________________________________________________________________

Fax:  703-435-3863                Email:  preschool@herndonumc.org