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.


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