GESHER L’TORAH PRESCHOOL 4320 KIMBALL BRIDGE RD ALPHARETTA, GA 30022
Child’s Name Date of Birth
Age in years + months on September 1, 2016: _________ years and _________ months
Parent/Guardian #1 Name Parent/Guardian #2 Name
Home Phone Number
Email Address
Cell Phone Number Home Phone
Email Address
Cell Phone Number
Address
City, ST ZIP Code City, ST ZIP Code
Place of Employment Place of Employment
Work Phone Number Work Phone Number
Employer’s Street Address
City/State/Zip
Child’s Living Arrangements: (check one):
Child’s Legal Guardian(s): (check one):
Employer’s Address
City/State/Zip
( ) Both Parents ( ) Mother ( ) Father ( ) Other
( ) Both Parents ( ) Mother ( ) Father ( ) Other
Class Enrollment:
_____ Two-Year-Old Program (Fishy Class)
Days per Week/Cost per Month:
______ Tuesdays and Thursdays (Members- $244/ Non-Members- $322)
______ Monday/ Wednesday/ Friday (Members- $354/ Non-Members- $442)
______ Mondays-Fridays (Members- $512/ Non-Members- $611)
I am currently a member “in good standing” of Congregation Gesher L’Torah: _____ yes _____ no
M F
Sex
I have ____children enrolled for the 2016-2017 preschool year and qualify for a 10% sibling discount to be applied to the younger sibling(s)’s tuition.
____ $120 one-time registration/supply fee is included with this enrollment form. Checks should be made out to GLTP.
____ Registration fee is non-refundable/non-transferable with the exception of those who do not get a preschool spot.
____Visa and MasterCard payments are accepted, but a 3% convenience fee will be added to your account.
____Additionally, I understand in order to maintain my enrollment status, first month’s (August) tuition is due by May 1,
2016.
Signature________________________________________________Date_____________________________
Office Use Only:
Check#______ CC Payment_____ Enrollment Form Signed_____ Date___________________________
Gesher L’Torah Preschool 2016-2017

GESHER L’TORAH PRESCHOOL 4320 KIMBALL BRIDGE RD ALPHARETTA, GA 30022
Hospital/Clinic Preference
Physician’s Name
Insurance Company
Phone Number
Policy Number
Allergies/Special Health Considerations
If your child’s medical condition is life threatening and will require the GLTP staff to store and possibly administer any medication, such as but not limited to inhaler or epi-pen, an additional “Allergy Action Plan” will need to be filled out, signed and turned in along with the child’s medication to the preschool office.
Gesher L’Torah Preschool cannot be responsible for administering emergency treatment in the event of a life-threatening emergency or any invasive procedure such as the administering of epi-pens unless this form has been signed and submitted to the preschool office.
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. I shall be responsible for payment for services.
Parent’s/Guardian’s Signature Date
Gesher L’Torah Preschool 2016-2017