2178 Friedberg Church Road Winston-Salem, NC 27127 (336)764-1840 fmpreschool.com

2008-2009 Registration

Please check desired class.

Two’s: 2 days/week… $125 Tuesday & Thursday _______

(Must be 2 by Oct. 16)

Three’s: 3 days/week… $145 Tuesday – Thursday _______

(Must be 3 by Oct. 16)

Four’s: 4 days/week… $165 Monday – Thursday _______

(Must be 4 by Oct. 16)

Readiness: 4 days/week… $175 Monday – Thursday _______

(Must be 5 by Dec. 31)

A non-refundable $60 registration fee is required with application.

Make checks payable to Friedberg Moravian Preschool.

Child’s Name______________________________________________________________

First Middle Last Preferred Name

Date of Birth_________________________ Home Phone_________________________

Address __________________________________________________________________

Street City State Zip Code

Mother’s Name_____________________________________Cell #________________

Employer________________________________________Wk.#________________

Father’s Name______________________________________Cell#________________

Employer________________________________________Wk#________________

Parent’s Marital Status: Married_______ Separated______ Divorced_______

Please let Director know of any special custody arrangements.

Siblings & Ages: ________________________________________________________

______________________________________________________________________

Emergency Contacts (other than parents):

1. Name________________________________________Relation_________________

Home Phone____________________Cell Phone_______________________

2. Name________________________________________Relation_________________

Home Phone____________________Cell Phone_______________________

Allergies:_______________________________________________________________

Medical Conditions:______________________________________________________

Child’s Doctor: ____________________________________Phone_________________

Address_______________________________________________________________

Field Trip Permission

___________________ has my permission to attend field trips planned by Friedberg Moravian Preschool. I will provide an approved child safety seat for my child and I give staff members permission to secure my child in the seat.

Parent signature__________________________________________________ date_______________

Playground and Play Equipment Policy

I give my permission for _______________________________________ to participate in all supervised and scheduled activities during the normal operation of a school day. I have seen the playground and inside play equipment. I understand that the staff will use proper safety procedures and precautions to insure the safety of my child.

Parent signature _________________________________________________ date _______________

Photo Permission

I give permission for my child’s photographs to be used (without name) on the Friedberg Moravian Preschool website. I understand that photographs will be used only in the Album sections and as highlights on the Home and information pages and cannot be downloaded.

_________________________________________________________________date_______________

Child’s name Parent signature