Online Registration Form | Crosspoint Preschool

Child Information

CHILDREN MUST BE FULLY IMMUNIZED PRIOR TO THE FIRST DAY OF SCHOOL!

Child's Name(Required)

First Last

Name you prefer your child be called at school(Required)

Sex(Required)

Male

Female

Date of Birth(Required)

Age as of September 1st(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Parent/Guardian Information

Father/Guardian’s Name

First Last

Cell Phone

Email Address

Place of employment

Work Phone

Mother/Guardian’s Name

First Last

Cell Phone

Email Address

Place of employment

Work Phone

Marital Status of Adults with Whom Child Resides

(Notify the Director of legal custody arrangement and bring copies of any custody papers if applicable.)

Other members of the household, other than parents. (Please indicate ages of siblings)

Class Enrollment

Note: Classes are scheduled according to demand and depend upon enrollment. $50 registration fee required for class placement.

Age Group

3 Year-old

4 Year-old

Pre-K Class

3 Year-Old Days Preference

Tuesday & Thursday

Wednesday & Friday

Pre-K Preference

M-Th (4 days)

M-F (5days)

4 Year-Old Days Preference

Tuesday & Thursday

Monday, Wednesday & Friday

In case of emergency, please list two people who may be contacted if we are unable to reach parents/ guardians.

Name

Phone

Family Physician

Name

Phone

General condition of child’s health

Is your child under a physician’s care for any medical conditions (including speech, hearing, eyesight, cardiac or orthopedic)

Yes

Please offer a brief explanation of medical condition

Has your child received OR is your child currently receiving any form of early intervention evaluation/services?

Yes

Please offer a brief explanation of intervention

Does your child have any allergies (contact, inhaled, ingested) including food?

Yes

Please offer a brief explanation of allergies

Are there any dietary restrictions (medical or religious) for your child?

Yes

Please offer a brief explanation of allergies

Are there any dietary restrictions (medical or religious) for your child?

Yes

Please offer a brief explanation of dietary restrictions

Physical, mental, or emotional limitations

If not from the U.S., what is your country of origin?

Primary language spoken at home

Does your child nap during the day?

Yes

When?

How Long?

Has your child had previous preschool school experience?

Yes

Where was the previous preschool experience?

Has your child attended church, neighborhood, or other group activities?

Does your child have experience playing with other children?

By nature, is your child:

Friendly

Aggressive

Shy

Withdrawn

Other

How would you explain your child's nature?

Does your child play well alone?

Yes

How does your child typically relate to new people and new situations?

Does your child stay with a sitter?

Rarely

Occasionally

Often

Has your child had any unusual experiences, such as an accident or trauma OR does your child have any strong fears? (For example: elevators, loud noises, fire trucks)

Yes

Explain unusual experience

Is your child potty trained?

Yes

Please Note: Your child must be potty trained prior to the first day of school. If your child is not potty trained by the first day of school, they may be removed from his/her classroom assignment, and no refund will be issued.

Is there any additional information the teachers should know to help make CrossPoint a more enjoyable experience for your child?

How did you hear about CrossPoint Preschool?

CrossPoint does not discriminate in providing services to children and their families based on race, color, national and ethnic origin, political beliefs, or marital status. Please note: No portion of the registration fee or advance-paid tuition is refundable.

Signature of Parent/Legal Guardian 1

Date

Registration Payment

NOTE: Submission of this form does not guarantee class placement. Once form is received, you will be contacted to confirm your registration, along with registration payment options.

Untitled