Register for the 2023-2024 Preschool School Year Step 1 of 4 25% What Do You Wish to Enroll in?*Preschool ONLYPreschool and Kid's Day OutContact InformationPlease 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?*Mother and FatherFatherMotherGrandparentOtherFather's Name* First Last Father's Occupation / Interests Father's Business PhoneFather'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 PhoneMom'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 PhoneGrandparent'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 PhonePrimary 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 PhoneAdditional 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Add a Second Address? Yes Child's Secondary Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Classes Being OfferedWhich Class Will Your Child Enroll in?* 3-Year Olds AM - Tuesdays & Thursdays (9:00 AM - 11:30 AM) - SORRY! CLASS IS FULL 3 Year Old PM - Tuesdays & Thursdays (12:30 PM - 3:00 PM) 3 & 4 Year Olds AM - Tuesdays & Thursdays (9:00 AM - 11:30 AM)- SORRY! CLASS IS FULL 4 Year Olds AM - Mondays, Wednesdays, & Fridays (9:00 AM - 11:30 AM) 4 Year Olds PM - Mondays, Wednesdays, & Fridays (12:30 PM - 3:00 PM) 4 Year Olds Extended Day - Mondays, Wednesdays, & Fridays (9:00 AM - 2:00 PM) - SORRY! CLASS IS FULL 5 Year Olds Enrichment AM - Mondays, Wednesdays, & Friday (9:00 AM - 11:30 AM) - SORRY CLASS IS FULL 5 Year Olds Enrichment AM - Mondays, Tuesdays, Wednesdays, & Thursdays (9:00 AM - 11:30 AM) 5 Year Olds Extended Enrichment All Day Class - Mondays, Wednesdays, & Fridays (9:00 AM - 3:00 PM) - SORRY CLASS IS FULL age requirements for classes in the 2022-23 school year3 Year Old Classes: Must be 3 by September 1, 20233 & 4 Year Old Classes: Must be 3 by September 1, 20234 Year Old Classes: Must be 4 by September 1, 20235 Year Old Enrichment Classes: Must be 5 by January 1, 2024Sorry, this class is full. Please make another selection.We are sorry this enrichment class is full, please check out and consider the 4 day enrichment class as an alternative. Call 412-372-6836 to discuss how you can extend their days.OPTIONAL Wishlist Classes - Would You Prefer This Option?4 Year Olds These classes may be added if enough interest is shown. Based on the class option you selected, please indicate if this alternative class time would be more desirable. 3 & 4 Year Old PM - Tuesdays & Thursdays (12:30 PM - 3:00 PM) OPTIONAL Wishlist Classes - Would You Prefer This Option?3 Year Olds These classes may be added if enough interest is shown. Based on the class option you selected, please indicate if this alternative class time would be more desirable. 3 & 4 Year Old PM - Tuesdays & Thursdays (12:30 PM - 3:00 PM) OPTIONAL Wishlist Classes - Would You Prefer This Option?5 Year Olds These classes may be added if enough interest is shown. Based on the class option you selected, please indicate if this alternative class time would be more desirable. 4 Day Enrichment PM - Mondays, Tuesdays, Wednesdays, & Thursdays (12:30 PM - 3:00 PM) Add-On Classes & ProgramsSpecial Music, Earth Explorers, and a physical fitness class are automatically included in the extended enrichment program!Special Music* Yes No Available for 3-year-olds, 4-year-olds, & 5-year-olds on Wednesdays or ThursdaysWhich 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 PAST Time* Yes No 3:00 - 5:00PM Daily Days of the Week Needed*Which Days do you Need the PAST Time Service? (Select all days you desire) Monday Tuesday Wednesday Thursday Friday Time Needed* What time range do need the PAST Time service (Between 3:00 PM and 4:00 PM)Sorry, this class is full. Please make another selection You can also contact the preschool director at crossroadspreschooldirector@gmail.com for additional availability. Doctor's InformationDoctor's Name* Doctor's Address* Doctor's Phone Number*Emergency ContactIf 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 TreatmentIn 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 LiabilityI 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 NeedsPLEASE READ AND CHECK ANY AREAS THAT MAY APPLY* Allergies Asthma Hearing Devices Glasses COVID Vaccine Received English as a Second Language Autism Spectrum Disorder Attention Deficit Disorder Physical Restrictions Therapeutic Support Staff (TSS) Individualized Education Plan (IEP) 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 CommentsPhoto ReleaseFrom 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 InformationHow Do You Prefer to Pay?*Monthly Online PaymentCheckCashWhat E-Mail Address Should We Use for Billing?* This will be the e-mail used for confirmation and all payment-related correspondence. Miscellaneous InformationAre 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 InformationThe 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 likeThe 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 TreatmentIn 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 LiabilityI, 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:NameThis field is for validation purposes and should be left unchanged.
