Good Samaritan School
Student Enrollment Form
CHILD’S FULL NAME:_____________________________________
NICKNAME:__________________________
D.O.B. _________________
Enrollment Date:_______________________________________
ADDRESS –STREET, CITY, STATE, ZIP:__________________________________________________________________________________________
PRIMARY LANGUAGE SPOKEN AT HOME:______________________________________ GENDER: (
) MALE
(
) FEMALE
Mother/ LEGAL GUARDIAN’S NAME ________________________________________________ HOME PHONE NUMBER: ___________________
PRIMARY ADDRESS – STREET, CITY, STATE, ZIP:__________________________________________________________________________________
BUSINESS NAME:_________________________________________________________________ WORK PHONE NUMBER:___________________
PRIMARY EMAIL ADDRESS:_________________________________________________________
CELL PHONE NUMBER:____________________
Father / LEGAL GUARDIAN’S NAME ________________________________________________ HOME PHONE NUMBER: ___________________
PRIMARY ADDRESS – STREET, CITY, STATE, ZIP:__________________________________________________________________________________
BUSINESS NAME:_________________________________________________________________ WORK PHONE NUMBER:___________________
PRIMARY EMAIL ADDRESS:_________________________________________________________
DOES CHILD RESIDE WITH BOTH PARENTS / LEGAL GUARDIANS? (
CELL PHONE NUMBER:____________________
) YES
(
) NO
LOCAL EMERGENCY CONTACTS – TO WHOM THE CHILD MAY BE RELEASED
1.
2.
NAME OF EMERGENCY CONTACT:
CONTACT PHONE NUMBER
_________________________________________________________________________
_________________________________________________________________________
RELATIONSHIP TO CHILD:
_________________________________________________________________________
NAME OF EMERGENCY CONTACT:
CONTACT PHONE NUMBER
_________________________________________________________________________
_________________________________________________________________________
RELATIONSHIP TO CHILD:
_________________________________________________________________________
NAME OF CHILD’S PHYSICIAN OR MEDICAL PROVIDER:____________________________________________________________________________
PHYSICIAN OR MEDICAL PROVIDER PHONE NUMBER:_____________________________________________________________________________
DATE OF LAST PHYSICAL EXAM:______________________________________________________________________________________________
NAME AND PHONE NUMBER OF CHILD’S DENTIST:______________________________________________________________________________
KNOWN ALLERGIES (INCLUDING MEDICATION):_________________________________________________________________________________
DIETARY RESTRICTIONS OR CULTURAL FOOD PREFERENCES:_______________________________________________________________________
PARENT / LEGAL GUARDIAN SIGNATURE: _________________________________________________ DATE:_____________________________
Good Samaritan Preschool * 1757 244th Ave NE, Sammamish, WA 98074 * (425)868-9544 * goodsamschool@outlook.com
Revised 3/15
Good Samaritan School
Enrollment Agreement
Child’s Name:_________________________________ DOB________________
Enrolling for:
Age Group:
Hours:
Days:
 2 ½ year old:
 3’s
 Before School Care  9:00 – 1:00
Monday
Tuesday

 9:00 – 3:00
Wednesday
4/5 (PreK)
 After School Care
Thursday
Friday
Please circle the specific days you would like your child to attend
Enrollment/Tuition Policies & Procedures
A non-refundable registration fee of $150 for the 1st child ($50 for each additional child) is due with registration.
Tuition for students enrolling after the 15th of the month will be charges a pro-rated amount of half months tuition.
Tuition is due the first of each month. Checks payable to GSS. A late fee of $25.00 will apply after the 10 th.
Late Pick-Up Fee - $1.00 per minute after the first five minutes of late pick-up. (applies to all students picked up after
their registered time)
Discounts
 Families enrolling multiple students will receive a 10% sibling discount on the lowest tuition rate.
 Families in good standing with Good Samaritan Church will receive a 10% discount.
Withdrawal from Program
Good Samaritan School requires a 30 day written notice if you wish to withdraw from the program for any reason.
Vacation/ Extended Leave Policy
We recognize the importance of family vacations as well as unexpected trips that arise. We will honor a 50% tuition
discount for one month (30 days) for any family who is gone for a minimum of four consecutive weeks at a time. If you
are gone longer than four weeks, the full month’s tuition for the following month will be due to hold your child’s spot.
I have read the Good Samaritan School’s Enrollment/Tuition Policies & Procedures and agree to all terms and
conditions.
____________________________________________
Signature
__________________
Date
Revised 3/15