412-372-6836 crossroadspreschooldirector@gmail.com

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3 Day Extended Enrichment Mondays, Wednesdays, & Fridays Registration

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Which Class Will Your Child Enroll in?*
- Enrichment - Mondays, Wednesdays, & Fridays Extended Enrichment
What Do You Wish to Enroll in?*
Contact Information
Please provide the following information for contact purposes.
Child's Full Name*
First Last
Child's Date of Birth*
MM slash DD slash YYYY
Name Child Should Learn to Write*
Child's Gender*
- Male
- Female
Home Phone*
Who is the Child's Primary Guardian?*
Father's Name*
First Last
Father's Occupation / Interests
Father's Business Phone
Father's Cell Phone*
- You Have Permission to Send Me Text Messages
Father's Email Address*
- Please Send Monthly Newsletters and Important Notices to this Email
Mother's Name*
First Last
Mother's Occupation / Interests
Mother's Business Phone
Mom's Cell Phone*
- You Have Permission to Send Me Text Messages
Mother's Email Address*
- Please Send Monthly Newsletters and Important Notices to this Email
Grandparent's Name*
First Last
Grandparent's Occupation / Interests
Grandparent's Business Phone
Grandparent's Cell Phone*
- You Have Permission to Send Me Text Messages
Grandparents's Email Address*
- Please Send Monthly Newsletters and Important Notices to this Email
Primary Contact's Name*
First Last
Primary Contact's Relationship to Child*
Primary Contact's Occupation / Interests
Primary Contact's Business Phone
Primary Contact's Cell Phone*
- You Have Permission to Send Me Text Messages
Primary Contact's Email Address*
- Please Send Monthly Newsletters and Important Notices to this Email
Add Additional Contact?
- Yes
Additional Contact's Name*
First Last
Additional Contact's Relationship to Child*
Additional Contact's Occupation / Interests
Additional Contact's Business Phone
Additional Contact's Cell Phone*
- You Have Permission to Send Me Text Messages
Additional Contact's Email Address*
- Please Send Monthly Newsletters and Important Notices to this Email
Child's Primary Address*
Street Address Address Line 2 City State ZIP Code
Add a Second Address?
- Yes
Child's Secondary Address*
Street Address Address Line 2 City State ZIP Code
Total Number in Family*
Please enter a number greater than or equal to 2.
Number of Brothers*
Number of Sisters*
Name of School Previously Attended
Where Did You Learn About Cross Roads Preschool?
Would you like duplicate class news/notices sent to another person on your behalf?
- Yes
- No
Name of Person*
Person's Email Address*
The Following People Have Permission to Pickup My Child:
Authorized Person #1
First Last
Relationship to Child
Add Additional Authorized Person?
- Yes
Authorized Person #2
First Last
Relationship to Child
Add Another Authorized Person?
- Yes
Authorized Person #3
First Last
Relationship to Child

Add-On Classes & Programs
Wishlist Classes
- 3 & 4 Year Olds - Tuesdays & Thursdays PM
- Enrichment - Mondays, Tuesdays, Wednesdays, & Thursdays PM
These classes may be added if enough interest is shown.
Special Music*
- Yes
- No
Available for 3-year-olds, 4-year-olds, & 5-year-olds on Wednesdays or Thursdays
Which Day Would You Like Your Child to Attend Special Music?*
- Wednesday
- Thursday
Earth Explorers*
- Yes
- No
Available for 4-year-olds & 5-year-olds
Meets Mondays from 11:30 AM - 12:30 PM
Kids in the Kitchen Cooking Class*
- Yes
- No
Available for 4-year-olds & 5-year-olds
Meets on Wednesdays the first 2 weeks of each month from 1:00 PM - 2:30 PM
Sorry, this class is full. Please make another selection.

Doctor's Information
Doctor's Name*
Doctor's Address*
Doctor's Phone Number*
Emergency Contact
If parents cannot be reached, whom should we call in an emergency? Please list a friend or relative who lives close.
Contact's Name*
Contact's Address*
Contact's Phone Number*
Permission for Medical Treatment
In the event that my child should require emergency medical treatment and reasonable attempts to contact me or the emergency person/s listed above have not been successful, I give my consent for the administration of emergency medical treatment deemed necessary by licensed physicians, dentists, and emergency personnel at the nearest hospital.*

Please sign your name above to acknowledge your agreement.
Today's Date*
MM slash DD slash YYYY
Waiver of Liability
I hereby agree that for any illness or injury sustained while attending preschool, I will use my own medical or health insurance to cover the cost of the illness or injury.*

Please sign your name above to acknowledge your agreement.
Today's Date*
MM slash DD slash YYYY
Special Needs
PLEASE READ AND CHECK ANY AREAS THAT MAY APPLY*
- Asthma
- Allergies
- Hearing Devices
- Ear Tubes
- Glasses
- Physical Restrictions
- Autism Spectrum Disorder
- Therapeutic Support Staff (TSS)
- English as a Second Language
- Individualized Education Plan (IEP)
- Attention Deficit Disorder
- Receive Services from Dart or Any Other Agency
- No Concerns at this Time
- Other
This information will be used to support your child and allow us to optimize their learning experience at Cross Roads Preschool.
Additional Comments
Photo Release
From time to time during the year, we put pictures in the local newspaper, on cable TV, and on our church’s web site to advertise upcoming events. These pictures are usually taken in the classroom showing the children involved in some special school activity. If you are willing to have your child participate, if he/she is chosen, please complete the form below.
I give permission for my child's picture to be used:*
- Yes
- No
Signature*
Today's Date*
MM slash DD slash YYYY
Payment Information
How Do You Prefer to Pay?*
What E-Mail Address Should We Use for Billing?*
Miscellaneous Information
Are You Currently a Member of Cross Roads Presbyterian Church?*
- Yes
- No
Are You a Military Family?*
- Yes
- No
**Child's immediate family

Kid's Day Out Registration Information
The infant room will be open on Monday through Friday mornings from 9 to 1, as long as there is a need.
Please indicate below the times you would like
The classroom for the older children will open at 9 a.m. Monday through Friday. Closing time will vary according to need (not later than 3:00 p.m.). The children are limited to 4 hours a day and no more than 3 days a week, unless there is an emergency.
Please indicate below the times you would like.
Permission for Medical Treatment
In the event that my child should require emergency medical treatment and reasonable attempts to contact me or the emergency person/s listed above have not been successful, I give my consent for the administration of emergency medical treatment deemed necessary by licensed physicians, dentists, and emergency personnel at the nearest hospital.
Signature*
Date*
MM slash DD slash YYYY
Waiver of Liability
I, the parent or guardian hereby agree that for any illness or injury sustained while attending Kid’s Day Out, I will use my own medical or health insurance to cover the cost of the illness or injury.
Signature*
Date*
MM slash DD slash YYYY
VOLUNTEERS NEEDED!
Would You Be Interested in Joining Our Volunteer Program?
- Yes
- No
The day(s) and time(s) that would work best for you:
Phone
This field is for validation purposes and should be left unchanged.

Come Visit Us!

Cross Roads Preschool and Kid's Day Out
at
Cross Roads Presbyterian Church
2310 Haymaker Road, Monroeville, PA 15146
412-372-6836