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Registration packet

Spumc Weekday school

Dear Parents,

Please take the time to fill out the 2010-2011 registration packet
and submit it with your $50.00 registration fee to hold your child’s
place in the Weekday School. Open spaces are filled on a first
come, first served basis. In order to assure your child’s place in
the Weekday School, it is recommended that you submit the
registration forms and fees as soon as possible.

SPUMC Weekday School will follow the new NC Public School


entry date of August 31st. Your child’s age must correlate with the
appropriate class. Our 4 & 5 year old Stepping Stones class is
designed for those children who would have met the previous cut-
off date for kindergarten, they must be 5 years old by December
31st.

We look forward to a wonderful year!

The Weekday School Board of Directors


Weekday School Staff
South Point United Methodist Church
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I am registering my child for the:


PMO Program ___________________ $55/ month Fridays
2-year-old class __________________ $105/ month Mon, Wed or Tues, Thurs (circle one)
3-year-old class __________________ $115/ month Tuesdays & Thursdays
4-year-old class __________________ $125/ month Mon, Wed & Fridays
4/5 year-old Stepping Stones class ___ $160/ month Monday through Friday

Child’s Name ____________________________________________________________


(First) (Middle) (Last)

Name your child prefers to be called __________________________________________

Child’s Birth date _______________________________ Child’s Age _______________

Parent or Guardian’s Name _________________________________________________

Address ________________________________________________________________

Home Phone _________________________ Work/ Cell Phone ____________________

E-Mail Address __________________________________________________________

Parent or Guardian’s Name _________________________________________________

Address ________________________________________________________________

Home Phone _________________________ Work/ Cell Phone ____________________

E-Mail Address __________________________________________________________

Siblings that live in the home (names and ages) _________________________________

Emergency Contact _______________________________________________________

Relationship to the child ___________________________________________________

Home Phone _________________________ Work/ Cell Phone ____________________

Please list any medical conditions that we should be aware of (allergies, asthma, diabetes,
etc) ____________________________________________________________________

Office Use Only


Registration Fee Paid: _______________________(Amt) Date: __________________
2

HELP US GET TO KNOW YOUR CHILD


Full name__________________ Birth date___________

What are some of your child’s favorite activities at home? _____

Has your child ever been in a school setting before? __________

Does your child get along well with other children? ___________

What are your child’s favorite snacks? ____________________

Does your child learn by watching, doing or both? ____________

What is your child’s favorite book? ______________________

What is your child’s favorite song or rhyme? _______________

Is there anything else you would like to share about your child?
3

PHYSICAL EXAMINATION
(Must be completed and signed by the examining physician)

Name of child ______________________________________________

Weight ____________ Height ____________ Heart ____________

Chest ____________ Throat ____________ Neck ___________

Abdomen ___________ CU ____________ EXT ____________

Neurological System _________________________________________

Teeth ____________ Skin ____________ Head ____________

Results of Tuberculin Test, if given: _____________________________


(Type) (Results)

Should activities be limited? ___________________________________

Recommendations: ___________________________________________

VACCINE #1 #2 #3 #4 #5
DTP/DT
Polio xxxxxxxxx
HiB xxxxxxxxx
Hepatitis B xxxxxxxxxx xxxxxxxxx
MMR xxxxxxxxxx xxxxxxxxxx xxxxxxxxx
Chicken Pox
Prevnar
Other

_________________________________________ ________________________
Physician’s Signature Date of Examination

_________________________________________ ________________________
Office Address Telephone Number
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Child’s Name _______________________________ Age _____ Birth date _________

Medical History
1. Is your child allergic to anything? Yes _____ No _____
If so, what? ________________________________________________________

2. Has your child had a serious illness, surgery or hospital stay? Yes _____ No _____
If so, please describe: ________________________________________________

3. Does your child have any physical handicaps? Yes _____ No _____
If so, please describe: ________________________________________________

4. Is your child currently under the care of a Doctor? Yes _____ No _____
If so, for what reason? _______________________________________________

5. Is there any family history of mental retardation ____; convulsions ____;


diabetes ____; heart trouble ____ ?

6. Does your child have frequent cold ____; coughs ____; tonsillitis ____;
ear infections ____; upset stomach ____; high fever ____ ?

Medical Information
Name of child’s Doctor ________________________________ Phone ____________
Office Address ___________________________________________________________

Name of child’s Dentist ________________________________ Phone ____________


Office Address ___________________________________________________________

Hospital Preference _______________________________________________________

Emergency Contact
If neither the father nor mother (Legal Guardian) can be reached, call:

Name _______________________________________________ Phone ____________


Relationship __________________________________________

Name _______________________________________________ Phone ____________


Relationship __________________________________________

I agree that the director may authorize the physician of his/ her choice to provide
emergency care in the event that neither the family physician nor I can be contacted
immediately. This is done with the understanding that every attempt will have been
made to contact the parents, the child’s physician and other persons listed for emergency
contact.

______________________ __________________________________________
Date Signature of parent or guardian
5

SPUMC Weekday School

Parents, please indicate if you would like to be


included with the following activities...

Initial

Name, address, phone number and


e-mail in our Weekday School Directory _____

Parent Names __________________________________________


Child(ren) __________________________________________
Address __________________________________________
__________________________________________
Phone number __________________________________________
E-mail __________________________________________

Interested in being a room parent _____


organizing fund raisers ______

Interested in being a mystery reader, sharing my


profession, hobby or interests with my child’s class ______
Hobby/ Interest/ Profession _______________________________

Interested in sharing my knowledge of music _____


Spanish _____ other _____ with the children on a regular basis

Permission to use child(ren)’s picture in materials


for the Weekday School (website, posters, etc) ______

Child’s Name __________________________________________


Class __________________________________________
Parent’s Name __________________________________________
Signature __________________________________________
Date __________________________________________
6

Emergency Contact Information


To be kept in Emergency Contact Folder

Child’s Name __________________________________________________

Phone Number ________________________ Birth Date _______________

Address ______________________________________________________
_____________________________________________________________
City State Zip Code

Mother’s (or Legal Guardian) Name ________________________________


Daytime Phone Number _________________________________________
Other Contact Numbers __________________________________________

Father’s Name _________________________________________________


Daytime Phone Number _________________________________________
Other Contact Numbers __________________________________________

In case of emergency, please list two people who can be contacted if you
cannot be reached.

Name and Relationship __________________________________________


Phone Number(s) _______________________________________________

Name and Relationship __________________________________________


Phone Number(s) _______________________________________________

Name of Your Child’s Doctor _____________________________________


Phone Number _________________________________________________

Hospital Preference _____________________________________________

Please list any known allergies for your child _________________________

Name of person(s) that are allowed to pick-up Child on regular basis _____
_____________________________________________________________
_____________________________________________________________
7

This is to acknowledge that I have received a copy of South Point United


Methodist Church Weekday School’s Handbook or have reviewed the
Handbook on-line. I have read and agree to uphold all policies and
procedures set forth in the Handbook. I am also aware that revision of such
policies and procedures can take place at any time and I will be made aware
of any changes in writing.

Child’s Name __________________________________________________

Parent’s Signature ______________________________________________

Date _________________________________________________________
8

SPUMC Weekday school t-shirts

We ask that each child in the 3, 4-year old and Stepping Stones classes
purchase a school t-shirt. These will be worn on field trips. Everyone is welcome
to purchase a shirt! We have adult sizes too! T-shirt order forms are included
and should be returned with registration fees. Returning students that already
have t-shirts do not need to purchase new ones unless they would like to! Thank
you in advance!

STUDENT NAME: ________________________________________

SHORT SLEEVE SHIRT YOUTH:

XS S M L XL XXL __________ x $8/ SHIRT


Circle size ordered Number of shirts

LONG SLEEVE SHIRT YOUTH:

XS S M L XL XXL __________ x $10/ SHIRT


Circle size ordered Number of shirts

SHORT SLEEVE SHIRT ADULT:

XS S M L XL XXL __________ x $10/ SHIRT


Circle size ordered Number of shirts

LONG SLEEVE SHIRT ADULT:

XS S M L XL XXL __________ x $12/ SHIRT


Circle size ordered Number of shirts

TOTAL: ____________ $__________

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