Westminster Preschool Registration - Westminster Presbyterian Church of Rockford IL

Child's Full Name*

First Middle Last

Name to be used at school*

Gender*

Male

Female

Birthdate*

Address

Street Address Address Line 2 City State ZIP Code

Primary Email Address*

Medical Information

Physician

Physician's Phone

Physician Address

Street Address Address Line 2 City State ZIP Code

Preferred Hospital

Known Allergies

In Case of Emergency

In case of emergency, name 2 local persons who will assume responsibility for your child if you cannot be reached.

Name of 1st Emergency Contact*

First Last

Mobile Phone*

Daytime Phone*

Address

Street Address Address Line 2 City State ZIP Code

Relationship to Child

Name of 2nd Emergency Contact*

First Last

Mobile Phone*

Daytime Phone*

Address

Street Address Address Line 2 City State ZIP Code

Relationship to Child

Pick Up Information

List the persons other than parents who are authorized to pick up your child. A written permission slip must be on file before anyone other than the following people can pick up your child. You may add to or update this list at any time upon request.

Name of Pick Up Person 1

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Relationship to Child

Name of Pick Up Person 2

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Relationship to Child

Name of Pick Up Person 3

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Relationship to Child

Payment Information

Tuition for our 4-day per week program (Monday-Thursday, 9-11:30am) for 3- & 4-year-olds is $240.00 per month, due on the first day of each month.

Registration Checklist & Fees*

$100 non-refundable registration/supply fee

$240 (first month's tuition)

Certified copy of the child's birth certificate (must be submitted before the first day of school)

Fees may be mailed to:

Westminster Church
ATTN: Westminster Preschool
2821 N. Bell School Road
Rockford, IL 61107

By checking this box, I agree to all fees listed above and that my child's spot may not be fully reserved until payment has been received.*

I agree

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Phone

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Preschool Registration

Preschool Registration

Mother / Guardian's Information

Father / Guardian's Information

Medical Information

In Case of Emergency

Pick Up Information

Payment Information

Our Mission

Our Staff