Farmers’ Dell Co-operative Preschool of Glanbrook Inc.
Membership Enrollment Form
Page 1 of 5
Registration Information – Part I
Age at time of Enrollment:
Child’s Name:
Date of Birth:
Address:
Postal Code:
Phone #:
Parent/Guardian (1)
Parent/Guardian (2)
Name:
Name:
Address (if different from above)
Address (if different from above)
Home Phone #:
Home Phone #:
Cell Phone #:
Cell Phone #:
E-mail Address:
E-mail Address:
Place of Employment:
Place of Employment:
Address:
Address:
Work Phone #:
Work Phone #:
Occupation:
Occupation:
Emergency Information
Contact Name:
Home Phone #:
Address:
Work Phone #:
Physician:
Phone #:
Address:
Does your child have:
Special diet or medical conditions?
Food or medication allergies?
Any medical treatment or medication which may need to be administered while you child is at school? Provide details below:
I hereby give permission for a physician to give necessary treatment in the case of an emergency situation where parents cannot be
reached and a delay, in the opinion of medical staff, would be detrimental to the health of my child. It is understood that every effort will
be made to contact the parents. This consent also gives the Supervisor permission to administer the above listed medications in the
event of an emergency.
Signature of Parent/Guardian(1)
Signature of Parent/Guardian (2)
Date
Farmers’ Dell Co-operative Preschool of Glanbrook Inc.
Membership Enrollment Form
Page 2 of 5
Registration Information – Part II
Are you a new or returning student to the Preschool
New 
How did you hear about our Preschool?
Returning 
(NOTE - if returning, please specify what year(s)
attended _____________)
 Alumni  Residential flyer/brochure  Community postings  Internet  Outdoor advertisement  Community event
 Referral (pls. provide name of referring party) ____________________  Other (pls. specify) ________________________________
NOTE : Tax receipts will be issued in February 2016 via email.
Enrollment Requested
JK Readiness I
Wednesday
Friday
JK Readiness II
Tuesday & Thursday
Integration
(Special Needs
Program)
Monday
Tuesday
Wednesday
Thursday
Friday
Alternative
Enrollment
Monday
Tuesday
Wednesday
Thursday
Friday
I wish to be:
Duty
*Non-Duty families are only exempt from monthly parent duty requirements at the
school, and are still required to participate in mandatory special fundraising events, coop job and cleaning duties.
Non – Duty
Additional Comments:
For office use only - Monthly Fee: $ ____________________________
Child Pickup Authorization
Name
1.
2.
Address
Phone #
Relationship
Farmers’ Dell Co-operative Preschool of Glanbrook Inc.
Membership Enrollment Form
Page 3 of 5
Membership Pledge
We have read the Parent Handbook and hereby agree to abide by the rules and regulations of the Executive Committee and the General
Membership. We agree to pay a non-refundable registration fee to hold child’s spot in class and monthly tuition fees based on Enrollment
payable the 1st day of the month, and to comply with health and insurance rules.
We understand that the required duties of all adult members of Farmers’ Dell Co-operative Preschool include:
 Mandatory attendance at every general membership meeting, as scheduled (5-6 per year) ** A missed meeting fee will be applied for
general membership meetings not attended.
 Participate in school functions, and school maintenance and cleaning
 Perform a co-operative job as assigned by Executive Committee
Duty members must:
 Participate as a teacher’s assistant in the classroom as scheduled. Scheduled days per month will vary according to Enrollment.
Non-Duty members are exempt from this requirement.
 Provide a Police Clearance, TB Test with written results and date of last Tetnus/Diptheria shot prior to working with children. NonDuty members are exempt from this requirement.
We understand that failure to comply with the membership pledge could result in the removal of my child from Farmers’ Dell Co-operative
Preschool program
Signature of Parent/Guardian(1)
Date
Signature of Parent/Guardian(2)
Supplementary Reserve Fee Pledge
Date
As a member of Farmers’ Dell Co-operative Preschool of Glanbrook Inc., we understand that the supplementary reserve fee is part of the fee
structure. A supplementary fee of $180.00 for the first child enrolled per school year has been established regardless of the number of
enrollment days. This supplementary reserve fee (as passed by membership vote) has been blended and included in the regular monthly
program fee totals based on $18 each month over the course of the 10 month school term and will be paid out as such. This supplementary
reserve fee cannot be waived or removed from the regular monthly fee obligations unless otherwise stated and/or approved by the Executive
Committee. A discount will apply for any siblings who are registered in the same year. Farmers’ Dell will continue to offer individual
fundraising campaigns throughout the year however participation is voluntary (save and except any mandatory special event fundraising
events – see applicable section) and any monies raised will help support the school directly and not individual supplementary reserve fee
requirements.
We have read, understood and agree to the Supplementary Reserve Fee Pledge and conditions as noted above.
Parent/Guardian (1) Signature
Date
Parent/Guardian (2) Signature
Date
Farmers’ Dell Co-operative Preschool of Glanbrook Inc.
Membership Enrollment Form
Page 4 of 5
Special Preschool Fundraising Events
We understand that Farmers’ Dell Co-operative Preschool will hold special fundraisers (Breakfast with Santa, etc.) throughout the school term
that will require mandatory participation by members. Any monies raised from special fundraising events will help support the school directly
and will not be applied to any fee requirements (i.e. enrollment, registration, supplementary reserve, etc.) unless otherwise stated and/or
approved by the Executive Committee.
We have read, understood and agree to the Special Preschool Fundraising Events and conditions as noted above.
Parent/Guardian (1) Signature
Date
Parent/Guardian (2) Signature
Date
Co-operative Jobs
Farmers’ Dell Co-operative Preschool is run by an elected Executive Committee. There is also a list of other vital jobs within the preschool that
must be filled by the membership. Each member of the preschool is required to perform one co-operative job.
The Executive Committee reviews membership Enrollment forms and assigns jobs based on skills, interests and job requests. It is understood
that I may not be assigned the job I’ve requested; however, I will not be assigned an Executive position, unless requested.
I have reviewed the job descriptions of the co-operative jobs and would be interested in filling one of the following positions:
Special interests and skills:
1.
2.
3
For office use only:
Co-operative job assigned: _________________________________ Date: _______________________
Trip Consent
I hereby give consent for my child to be taken on supervised trips, provided that I am informed of each trip in advance. I will not hold any
person in attendance at the school responsible in case of accident, contraction of illness or loss of personal property while on the trip. If
my child has suffered an accident or sudden illness while on a trip, I hereby give consent for my child to receive emergency medical
treatment, if I cannot be reached and a delay, in the opinion of medical staff, would be detrimental to the health of my child. I understand
that the school’s insurance coverage extends to registered children only.
Signature of Parent/Guardian
Print Name
Date
Farmers’ Dell Co-operative Preschool of Glanbrook Inc.
Membership Enrollment Form
Page 5 of 5
Image Release Consent
I understand that in the course of activities, members and staff of Farmers’ Dell Co-operative Preschool may capture my child’s image
and/or voice on still photograph, motion picture film, audio tape, video tape or digital media. These photos are typically kept in photo
albums; however they could be used as promotional material.
I hereby agree that this material may be used solely to promote the preschool, in whole or in part, within the community, on
Farmers’ Dell Co-operative Preschool’s website, in newsletters and in the classroom.
I do not give permission to use this material to promote the preschool, in whole or in part.
I hereby agree that any photos (still or video) that I may take of the preschool children during class time, outdoors or at
special preschool events will not be used on the internet (ie. Facebook, MySpace or e-mail, etc.)
Print Child’s Name
Signature of Parent/Guardian
Print Parent/Guardian’s
Name
Date