Preschool Registration Form printable pdf download

Preschool Registration Form

2101 Woodland Rd.

Jeffersonville, IN 47130

(812) 283-3936

Simmonds’ preschool registration form:

(Please print neatly)

Child’s name: ___________________________________________________

Child’s age: ___________

Birthdate: ______________________

Parents/Guardians: ______________________________________________

Address: _____________________________________________________

City: __________________________State: __________Zip: ______________

Telephone #: ___________________ Alternate #: ______________________

Emergency Contact: _______________________________________________

Relationship: ___________________________ Phone #: __________________

Alternate #: ____________________________________________________

With whom does the child live? _______________________________________

Does your child have any allergies? ____________________________________

Names of people authorized to pick up your child:

____________________________

Relationship: ___________________

____________________________

___________________

____________________________

___________________

Please circle the class/es you are enrolling for:

Wed. Creative Arts

Tues./Thurs. Academics

3 Day Preschool

$60 per month

$85 per month

$110 per month

*Please note that if your child is either 2 years old or not potty trained by September 1

there is an

additional charge of $15 per month for tuition. If those circumstances change by mid-term (Christmas

break), your monthly tuition rate will be adjusted at that time.

**Please return this form with your $50.00 registration fee to cover the cost of supplies and reserve

your child’s slot. Tuition will be due the first day of class in September.

Preschool Registration Form