2015 - 2016 SCHOOL YEAR
SALEM PRE·SCHOOL INFORMATION SHEET
Your child's pre-school teacher needs to understand as much as possible about your child to join you in the task of
providing the best for him/her now, The information you supply below will be used for this purpose. Please
attach a photograph (one that does not need to be returned) of your child. Prior to July 1,2015, please mail
this completed form, a photo of your child, and a check for $35 to Salem Pre-school (which will cover the
first semester's activity fee) to Salem Pre-school, P.O. Box 111, Osceola, IN 46561. Thank you.
CHILD’S NAME
____________
NAME YOU WANT YOUR CHILD CALLED
NAME/BIRTH DATE OF SISTERS/BROTHERS (Please indicate if these are step brothers/sisters and if they
live with the child)
_______________________________________________________________________________
HOME PHONE
LISTED?
EMAIL
CELLPHONES: Mom
Dad
CHILD'S T-SHlRT SIZE
E-MAIL
STREET ADDRESS
CITY/STATE _______________________________________________ ZIP
FATHER'S NAME
Place of Employment
Phone __________________________Occupation
MOTHER'S NAME
Place of Employment
Phone
Occupation
STEPPARENT or GUARDIAN'S NAME
Place of Employment
Phone
Occupation
CHILD LIVES WITH: Parents_____ Mother
Father
Step Father and Mother___ Guardian
Other
Step Mother and Father
__
__
__
_
PLEASE LIST AT LEAST 2 INDIVIDUALS WITH THEIR PHONE NUMBERS (other than
parents/guardians) THAT WE MAY CONTACT IN CASE OF EMERGENCY. (Please list them
in order of calling priority.)
__
CHILD CARE PROVIDER (if applicable)
Phone
__
__
__
NAME AND PHONE NUMBER OF PERSON PICKING CHILD UP FROM SCHOOL
IF YOUR CHILD HAS ALLERGIES, PLEASE INDICATE WHAT THEY ARE, HOW THEY
ARE TREATED, AND IF THERE ARE ANY SPEClAL PRECAUTIONS WE NEED TO TAKE.
ARE THERE ANY SPECIAL HEALTH CONDITION/S WE SHOULD BE AWARE OF?
________
____________________________________________________________________________________________________
____________________________________________________________________________________________________ .
ARE THERE ANY ACTIVITIES WHICH YOUR CHILD SHOULD AVOID?
____________
____________________________________________________________________________________________________
DOES YOUR CHILD HAVE A PET/S?
_____ KIND/S AND NAME/S
___________
\
HOW DID YOU FIND OUT ABOUT SALEM PRE-SCHOOL?
CHILD’S DEVELOPMENT
SPEECH/HEARING:
Does your child have any speech difficulties? (For example: stuttering, lisping, faulty enunciation)
Are you enrolled in any program for speech? __________ Where? _________________________________________
Does your child have any difficulty hearing? __________ ________________________________________________ _
SOCIAL PARTICIPATION:
How does your child relate to playmates? _________________________________________________________
____________________________________________________________________________________________
With whom does s/he play? _____________________________________________________________________
____________________________________________________________________________________________
What group experiences has your child had with children his/her age? _____________________________________
_______________________________________________________________________________________________
How does your child relate to adults? _______________________________________________________________
______________________________________________________________________________________________
EMOTIONAL:
Does your child have any fears? Please explain. _____________________________________________________
_____________________________________________________________________________________________
Has s/he any behavior difficulties? __________________________________________________________________
_______________________________________________________________________________________________
SELF TENDENCIES:
Is s/he obedient? _________________________
Does s/he resist help? _____________________
Does s/he give up easily? __________________
Does s/he cry easily? _____________________
________________________________________________________
_________________________________________________________
_________________________________________________________
________________________________________________________
CHILD'S INTERESTS:
What things does your child enjoy doing at home?
What are her/his favorite toys? ___________________________________________________________________
WHAT SCHOOL WILL YOUR CHILD BE ATTENDING FOR KINDERGARTEN?_________________
_____________________________________________________________________________________________
IS THERE ANYTHING WE NEED TO KNOW ABOUT YOUR CHILD’S TOILETING HABITS? ____________
_____________________________________________________________________________________________
NO ____ _
PLEASE DESCRIBE THE TYPE OR METHOD/SOF DISCIPLINE USED IN YOUR HOME: ________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PLEASE USE 5 WORDS TO DESCRIBE THIS CHILD
Mother _______________________________________________________________________________________
Father ________________________________________________________________________________________
IS THERE ANYTHING ELSE ABOUT THIS CHILD OR HIS/HER SITUATION THAT THE TEACHERS
NEED TO KNOW TO UNDERSTAND THIS CHILD MORE FULLY?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
DO YOU HAVE A CHURCH AFFILIATION? YES ____ ________________
NO
New Salem United Methodist Church would be happy to share information with you concerning our church. Feel
free to call the church at 574-674-2882, the preschool office at 574-674-8293, or Pastor Michael at 574-340-3022.
PHOTOGRAPHIC RELEASE: I/we hereby consent and authorize Salem Pre-school to take and use
pictures or video films of my/our child/ren at school or school functions. The pictures may be used for
educational and public relations purposes.
Signature of parent/s or guardian/s and date
INFORMATION RELEASE: I am willing for Salem Pre-school to release my name, phone number, and/or
address to another adult associated with New Salem Pre-school/Church during this 2015 - 2016 school.
Signature of parent/s or guardian/s and date
I/WE understand that the New Salem United Methodist Church Pre-school does not have insurance for students
transported in private vehicles.
Signature of parent/s or guardian/s and date
I/WE AGREE TO SUBMIT IN WRITING any changes to the information I have provided on this form
including, but not limited to changes in employment, phone number/s, address, and medical information.
Signature of parent/s or guardian/s and date
I/WE UNDERSTAND these authorizations shall remain in effect until July 1, 2016.
Signature of parent/s or guardian/s and date
I/WE UNDERSTAND that the $75.00 registration fee I am paying for ___________________ _____
is NOT refundable and IS non-applicable.
_________________________________________________________________________
Signature of parent/s or guardian/s and date
THIS FORM WAS COMPLETED ON (DATE)
NEW SALEM UNITED METHODIST CHURCH INCORPORATED
PRE-SCHOOL
WAIVER, RELEASE OF LIABILITY, INDEMNIFICATION, AND CONSENT
This is an important document that affects your legal rights and obligations.
Please read it carefully. All parents or legal guardians of students enrolled in the
New Salem United Methodist Church Incorporated Pre-school (the "School") for
the 2015/2016 school year MUST sign this form. Thank you.
In consideration and as a condition of my child's enrollment in the School:
1. I Voluntarily elect to accept and solely assume all risks of accidental injury or
damage to my child incurred or suffered by my child while attending the School,
except to the extent such injury or damage is caused by the negligent act or failure
to act of the School or its employees.
2. I hereby waive, release, discharge, agree not to sue, and agree to indemnify and
hold harmless the School and its owners, officers, agents, servants, employees, and
all affiliates, for any claims, damages, costs including attorneys fees, or causes of
action which I have or may have in the future as a result of damages, injuries,
including death, sustained or incurred by my child as a result of accidental injury
or damage to my child except to the extent such injury or damage is caused by the
negligent act or failure to act of the School or its employees.
I further consent to the School and its employees obtaining or providing my child with
such medical treatment as may be deemed advisable in the event of my child's injury,
accident, or illness while attending the School, and assume full responsibility for the costs
of any such medical treatment.
I ACKNOWLEDGE THAT I HAVE READ AND THAT I UNDERSTAND EACH AND
EVERY ONE OF THE ABOVE PROVISIONS IN THIS WAIVER, RELEASE OF
LIABILITY, INDEMNIFICATION, AND CONSENT AGREEMENT AND AGREE TO
ABIDE BY THEM.
Printed Name: ______________________________________ ________________________
Signature: __________________________________________ _
________
Student's Name: _____________________________________________________________
Date: ________________________________________________________________________ Waiver,
Release of Liability, Indemnification, and Consent (00086603).WPD