Registration packet

Spumc Weekday school

Dear Parents,

Please take the time to fill out the 2011-2012 registration packet,
submit it with your $55.00 registration fee and applicable activity
fee (fees differ for each class) to hold your child’s place in the
Weekday School. Open spaces are filled on a first come, first
served basis. In order to assure your child’s place in the Weekday
School, it is recommended that you submit the registration forms
and fees as soon as possible.

SPUMC Weekday School will follow the new NC Public School

entry date of August 31st. Your child’s age must correlate with the
appropriate class. Our 4 & 5 year old Stepping Stones class is
designed for those children who would have met the previous cut-
off date for kindergarten, they must be 5 years old by December
31st.

We look forward to a wonderful year!

The Weekday School Board of Directors

Weekday School Staff
South Point United Methodist Church
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SPUMC Weekday School

2011 – 2012 Payment Guidelines

Class Registration Activity Fee Monthly Extra Day

Fee (non-refundable) Tuition
(non-refundable)

PMO $55/ school $0 $55/ month N/A

year

2s $55/ school $20/ school $105/ month N/A

year year

3s $55/ school $40/ school $115/ month $30/ month

year year

4s $55/ school $55/ school $135/ month* $30/ month

year year

Stepping Stones $55/ school $55/ school $175/ month* N/A

year year

*Monthly tuition for the 4’s and Stepping Stones Class includes Play Spanish tuition.

To confirm your child’s place in the Weekday School, both the non-refundable
Registration Fee and the non-refundable Activity Fee must be paid at the time of
registration. The Activity Fee will include everything except Scholastic book orders,
Pennies from Heaven, t-shirt sales, pictures and our 2 fundraisers (all optional). For field
trips including parents, these fees cover the cost of one parent. They also include a
Handwriting Without Tears Workbook (3s, 4s & SS) for your child and a monthly
subscription to Scholastic magazine (4s & SS).
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I am registering my child for the:

PMO Program (Wed) ___________________
2 year-old class (Mondays & Thursdays) ___________________
3 year-old class (Tuesdays & Thursdays) ___________________
3 year-old extra day (Wednesdays) ___________________
4 year-old class (Monday, Wednesday, Friday) ___________________
4 year-old extra day (Thursdays) ___________________
4/5 year-old Stepping Stones class (Mon - Fri) ___________________

Child’s Name ____________________________________________________________

(First) (Middle) (Last)

Name your child prefers to be called __________________________________________

Child’s Birth date _______________________________ Child’s Age _______________

Parent or Guardian’s Name _________________________________________________

Address ________________________________________________________________

Home Phone _________________________ Work/ Cell Phone ____________________

E-Mail Address __________________________________________________________

Parent or Guardian’s Name _________________________________________________

Address ________________________________________________________________

Home Phone _________________________ Work/ Cell Phone ____________________

E-Mail Address __________________________________________________________

Siblings that live in the home (names and ages) _________________________________

Emergency Contact/ Relationship ____________________________________________

Home Phone _________________________ Work/ Cell Phone ____________________

Office Use Only

Registration Fee Paid: _____________________(Amt) Date: __________________
Activity Fee Paid: ______________________(Amt) Date: __________________
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PHYSICAL EXAMINATION
(Must be completed and signed by the examining physician)

Name of child ______________________________________________

Weight ____________ Height ____________ Heart ____________

Chest ____________ Throat ____________ Neck ___________

Abdomen ___________ CU ____________ EXT ____________

Neurological System _________________________________________

Teeth ____________ Skin ____________ Head ____________

Results of Tuberculin Test, if given: _____________________________

(Type) (Results)

Should activities be limited? ___________________________________

Recommendations: ___________________________________________

VACCINE #1 #2 #3 #4 #5
DTP/DT
Polio xxxxxxxxx
HiB xxxxxxxxx
Hepatitis B xxxxxxxxxx xxxxxxxxx
MMR xxxxxxxxxx xxxxxxxxxx xxxxxxxxx
Chicken Pox
Prevnar
Other

_________________________________________
________________________
Physician’s Signature Date of Examination

_________________________________________
________________________
Office Address Telephone Number
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Child’s Name _______________________________ Age _____ Birth date _________

Medical History
1. Is your child allergic to anything? Yes _____ No _____
If so, what? ________________________________________________________

2. Has your child had a serious illness, surgery or hospital stay? Yes _____ No _____
If so, please describe: ________________________________________________

3. Does your child have any physical handicaps? Yes _____ No _____
If so, please describe: ________________________________________________

4. Is your child currently under the care of a Doctor? Yes _____ No _____
If so, for what reason? _______________________________________________

Medical Information

Hospital Preference _______________________________________________________

I agree that the director may authorize the physician of his/ her choice to provide
emergency care in the event that neither the family physician nor I can be contacted
immediately. This is done with the understanding that every attempt will have been
made to contact the parents, the child’s physician and other persons listed for emergency
contact.

______________________
__________________________________________
Date Signature of parent or guardian
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SPUMC Weekday School

Parents, please indicate if you would
like to be included with the following activities...

Initial

Name, address, phone number and

e-mail in our Weekday School Directory _____

Interested in being a room parent _____

organizing fund raisers _____

Interested in being a mystery reader, sharing my

profession, hobby or interests with my child’s class _____
Hobby/ Interest/ Profession _____________________

Interested in sharing my knowledge of music _____

Spanish with the children on a regular basis _____

Permission to use child(ren)’s picture in materials

for the Weekday School (website, posters, etc) _____

This is to acknowledge that I have received a copy of

South Point United Methodist Church Weekday School’s
Handbook or have reviewed the Handbook on-line.
I have read and agree to uphold all policies and procedures
set forth in the Handbook. I am also aware that revision of
such policies and procedures can take place at any time
and I will be made aware of any changes in writing. _____

Child’s Name __________________________________________

Class __________________________________________
Parent’s Name __________________________________________
Signature __________________________________________
Date __________________________________________
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Emergency Contact Information

To be kept in Emergency Contact Folder

Child’s Name __________________________________________________

Phone Number ________________________ Birth Date _______________

Address ______________________________________________________
_____________________________________________________________
City State Zip Code

Mother’s (or Legal Guardian) Name ________________________________

Daytime Phone Number _________________________________________
Other Contact Numbers __________________________________________

Father’s Name _________________________________________________

Daytime Phone Number _________________________________________
Other Contact Numbers __________________________________________

In case of emergency, please list two people who can be contacted if you cannot be reached.

Name and Relationship __________________________________________

Phone Number(s) _______________________________________________

Name and Relationship __________________________________________

Phone Number(s) _______________________________________________

Hospital Preference _____________________________________________

Please list any known allergies for your child _________________________

Name of person(s) that are allowed to pick-up Child on regular basis _____
_____________________________________________________________
_____________________________________________________________
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SPUMC Weekday school t-shirts

We ask that each child in the 3, 4-year old and Stepping Stones classes
purchase a school t-shirt. These will be worn on field trips. Everyone is welcome
to purchase a shirt. We have adult sizes too! The t-shirt order form is below and
should be returned with registration fees. Returning students that already have t-
shirts do not need to purchase new ones unless they would like to. Thank you in
advance.

STUDENT NAME: ________________________________________

CLASS: ________________________________________________

SHORT SLEEVE SHIRT YOUTH:

XS S M __________ x $10/ SHIRT

Circle size ordered Number of shirts

SHORT SLEEVE SHIRT ADULT:

XS S M L XL XXL __________ x $12/ SHIRT

Circle size ordered Number of shirts

TOTAL: ____________ $__________