Preschool Registration Form Page 2
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1
2Authorization Form
Emergency Treatment
Child’s name
Phone
Parent or guardian
Work phone
Alternate phone
Parent or guardian
Work phone
Alternate phone
Physician
Phone
Insurance
List below the name and phone number of two friends or relatives that we can call in case of an emergency
when you can’t be reached (available during preschool hours with transportation and a valid driver’s license).
Name
Phone
Name
Phone
(Child’s name)
I understand that every effort will be made to contact the parent if
needs medical or surgical treatment. However, if it is impossible to do so, I hereby give my permission to an
emergency physician to secure proper treatment, or hospitalize, order injections, to anesthetize, or X-ray or do
surgery for my child.
Child’s birthdate
Parent/Guardian signature
Date
Tuition Agreement:
Upon enrolling your child in Little Pilgrims Preschool, please be certain that you understand and agree to the
following tuition policy.
1. A non-refundable registration fee of $100.00 is required upon enrollment.
2. Tuition is due the second week of each month. A late charge may be levied at the end of the month.
3. A fee may be charged for any NSF checks.
4. If it is necessary to withdraw your child from school before the end of May, paid tuition will be
refunded if the teacher is given 30 days notice.
5. Monthly tuition is an average of all the school days for the entire nine months, September through
May. It takes into consideration school holidays, in-service days, and 5-week months.
Please sign here to indicate you have read and agree to the tuition agreement
Parent/Guardian signature
Date
Mission Statement
*
As an outreach of Pilgrim Lutheran Church, our educational program will assist young children in their total
developmental growth through the grace of Jesus Christ.
Please attach a current copy of your student’s
immunization record and the $100 Registration fee
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