Memorial Lutheran JUMP START
Application for Admission
Date received____________
Check #_________________
School Year______________
________________________
________________________
June 2015
1. Child’s Full Name ________________________________________________________Gender M or F
(First)
(Last)
(Circle one)
2. What name should the teachers use in addressing your child? ___________________________________
3. Name you want your child to learn to write/nickname? _________________________________________
4. Date of birth(month, day, year)___________________________________________Age___________
5. Parent/s or Guardians Name______________________________________________________________
6. Address_______________________________________________________________________________
City and State__________________________________________________________________________
7. Family email___________________________________________________________________________
(Please print clearly, we will use for updates, important information)
8. Home Phone_____________________
9. Dad’s Cell______________________________
Mom’s Cell____________________________________
10. Dad’s Employer and phone________________________________________________________________
______________________________________________________________________________________
Dad’s Occupation/position_________________________________________________________________
11. Mom’s Employer and phone________________________________________________________________
_______________________________________________________________________________________
Mom’s Occupation/position_________________________________________________________________
12. Name, and phone (cell &home) of relatives or friends who may be contacted in case of emergency. In addition, those
listed you authorize to pick up your child from preschool. List at least two.
Please list relationship to child, for example Grandma, friend, Aunt, neighbor etc.
Name
Relationship
Phone#(s)
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________________________________________
ALLERGIES: please list any allergies your child may have (food, medication etc) or any medical situation we should
be aware of: _________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
NOTE: We operate a peanut free preschool.
We are not physically equipped to satisfactorily handle pupils who do not respond or adjust to the daily routine in
preschool, who demand too much individual attention, or who definitely show emotional disturbance. If after
consultation with the parents we find that the child has not improved, we reserve the right to ask for withdrawal of
the child.
How did you hear about Memorial Lutheran Preschool? (friend, social media, newspaper)_____________________
__________________________________________________________________________________________________
I am enrolling my child in Memorial Lutheran JUMP START Program for the 2015-2016 school year. Tuition is $12 per
Monday payable monthly. After 2nd preschool day of the month you will be assessed a late fee of $10.00. Checks payable
to Memorial Lutheran Preschool.
CHOOSE ONE:
Monday only from 8:30-10:30 (minimum of 5 children)
Monday only from 10:45-12:45 (minimum of 5 children)
Jumpstart will follow the SASD calendar and the MLC preschool calendar. Transportation will be provided by the Parents.
__________________________________________ ___________
Signature of Parent or Guardian
Date
If you DO NOT want your child’s picture to appear in local publications, facebook or the church website, please
initial in box.
Please return this form with the $24.00 per family application fee .
Memorial Lutheran Preschool
34 East Orange Street Shippensburg, PA. 17257
preschoolmlc@gmail.com
717-532-4614