2022-2023 STUDENT ENROLLMENT

Please fill out this online enrollment form or print out the pdf and drop it off at First United Methodist Church between 9am & 1pm Monday thru Friday. Or the form can be mailed to:

Kristen Breslin

First United Methodist Preschool Director

101 East Jefferson Street

Charlottesville, VA 22902

Student Information

Child's Name*

Preferred Name (if different):

Class* 2 3 Pre-K Transitional Kindergarten

Gender Female Male

Birthdate*

Primary Phone Number

Home Address*

City*

State*

Zip Code*

Has your child attended preschool before?* Yes No

If YES, what preschool did your child attend?

Dates your child attended above preschool

How did you hear about our preschool?

Family Information

Mother/Guardian's Name*

Address (if differnt than above)

City

State

Zip Code

Occupation*

Primary Phone*

Alternate Phone

Email*

Father’s/Guardian’s Name*

Address (if different than above)

City

State

Zip Code

Occupation*

Primary Phone*

Alternate Phone

Email*

Status of Parents*

Name, age, and gender of other children in the family*

List any other persons living in your household and their relationship to your child*

Emergency Contact information

Please list information for local persons to be contacted in the event of an emergency or illness if parents/guardians cannot be reached.

Name*

Full Address*

Primary Phone*

Alternate Phone

Relationship to Child*

Name*

Full Address*

Primary Phone*

Alternate Phone

Relationship to Child*

HEALTH INFORMATION

AUTHORIZATION FOR THE EMERGENCY MEDICAL TREATMENT OF MINORS

I/We, being the parent(s) or guardian(s) of the above-named minor child, do hereby appoint all of First United Methodist Preschool to act in my/our behalf in authorizing emergency medical treatment (including, without limitation, dental, surgical and hospitalization) for the above-named minor in the event I/we am/are immediately unavailable to make such decisions.

Mother’s/Guardian’s Signature*

Date*

Father’s/Guardian’s Signature*

Date*

List any allergies, conditions, or other health concerns that would be needed to assist the staff or medical personnel in an emergency situation:*

HOSPITALIZATION COVERAGE

Preferred Hospital*

Insurance Company and/or Government Program*

ID or Contract Number*

PHYSICIAN INFORMATION

Primary Care Physician*

Phone*

Dentist*

Dentist Phone*

Other

Other Phone

PERMISSION AND ACKNOWLEDGEMENT OF POLICIES AND PROCEDURES

PICK-UP PERMISSION

The person(s) listed below have permission to pick-up my child from Preschool. Please notify the Director if your child will be picked up by someone not listed on this form.

Name*

Phone*

Relationship*

Name*

Phone*

Relationship*

Name

Phone

Relationship

Other Permissions

I give permission for my child to receive first aid for minor injuries from the teachers at First United Methodist Preschool. The teacher will determine whether it is necessary or appropriate to notify the parent/guardian immediately or at pick-up time.

Please initial the appropriate response.*

I give permission for First United Methodist Preschool to take my child on field trips, and I understand I will be notified when these trips occur.*

I give permission for my child to be photographed/recorded while at preschool or on a preschool related trip. I understand the resulting photographs and videos will be used only for purposes directly related to First United Methodist Preschool, and I authorize such use.*

Signatures

Mother’s/Guardian’s Signature*

Date*

Father’s/Guardian’s Signature*

Date*

Thank you for your application. You will be contacted either way and offered a spot as they are available.

All the best,

Kristen Breslin

First United Methodist Preschool Director

434-296-6682

fump@cvillefirstumc.org