ShineKids Preschool Registration

Please fill out one registration form per student.

First Parent/Guardian Contact Information

Full Name

Address

Phone #

Employer

Work Phone #

Second Parent/Guardian Contact Information

Full Name

Phone #

Address

Employer

Work Phone #

Student Information

Student's Full Name

Name we should call your child in preschool.

Name you would like your child to learn to write at preschool.

Student's Birthdate

Student's Address

Household Information

Please list the names and relationships of all people who live with the student.

Emergency Contacts

Emergency Contact Name 1

Phone #

Emergency Contact Name 2

Phone #

Emergency Contact Name 3

Phone #

School and Church

Where does the student attend church?

When will the student attend Kindergarten?

What are your elementary school plans?

Public School Virtual School Private or Charter School Homeschool Other

What school district will the student attend?

What elementary school will the student attend?

Will ShineKids Preschool be the student's first school experience?

Yes No

What other group settings has the student attended regularly?

How did you learn about ShineKids Preschool?

Why do you wish to have your child enrolled in a preschool program?

Has your child been evaluated by or received services from Early Intervention or IU13? Please list services.

Do you plan to have your child evaluated by Early Intervention Services or the IU13 for speech, OT, PT, or behavioral needs? If so, please explain.

Please list any special learning needs we should know about.

Please list any fears or anxieties that we should know about.

What are the student's strengths?

What does the student love to do?

Health Information

Pediatrician/Primary Care Physician

Pediatrician/Primary Care Physician Phone

Hospital Preference

Please list any allergies we should be made aware of.

Please list foods the student should avoid.

Please mention any medical history information not listed above that you think we should know about.

Is the student's immunization records up-to-date? (we do not require a physical record)

Yes No

Preferred Contact Methods

Preferred Email

Preferred Voice Phone #

Preferred Text Phone #

Class Selection & Payment

Please select all that apply to this student.

Registration cost per student is $50.

Select Class(es)

2.5/4 year old class(Wednesday) 3/4 year old class (Tuesday & Thursday) Pre-K (Tuesday, Wednesday & Thursday) Lunch Bunch (Tuesday) Lunch Bunch (Thursday)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Registration Payment $50.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

ShineKids Preschool Registration

Description

Please Fix the Following