Registration for the 2020-21 School Year-PreKRegistration Pre-KOffline
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Child's Name
First Name Middle Name Last Name
Age
Birthdate MM/DD/YYYY
Gender
*Please note: Children must be 3 years old by September 1st and toilet-trained.
Program Requested
If interested in having your child ride the van, please list the Name and Address where the child will be picked up and dropped off for the van.
Name
First Name Last Name
Address
Address1 Address2 City State Zip
Choice of Payment Plan
Name child prefers to be called
Nick Name
Father's Name
First Name Last Name
Occupation
Employer
Religion
Work Phone
Area Code Number Extension
Cell Phone
Area Code Number
Mother's Name
First Name Last Name
Occupation
Employer
Religion
Work Phone
Area Code Number Extension
Cell Phone
Area Code Number
Home Mailing Address
Address1 City State Zip
Home Phone
Area Code Number
Email
Number of children in the family
Birth order of this child
Daycare provider and phone number
 
Emergency Information  
In the event of an emergency, Sts. Peter & Paul School is authorized to obtain EMERGENCY MEDICAL or DENTAL CARE even if the school is unable to immediately make contact with the parent/guardian.
During an emergency, Sts. Peter & Paul School is authorized to contact the following person when parent or guardian cannot be reached.
Do you agree? Name Date (MM/DD/YYYY)
Alternate emergency contact person's name
First Name Last Name
Phone
Area Code Number
Relationship to child
Child's doctor's name
First Name Last Name
Doctor Phone
Area Code Number
Hospital Choice
Does your child have health insurance?
Company
ID #
Child's Dentist Name
First Name Last Name
Dentist Phone
Area Code Number
Does child have dental insurance?
Company
ID
Any other healthcare specialist?
Phone
Area Code Number
Type of Specialty
Does your child have have any physical or medical limitations? (Please describe)
Does your child have any allergies? (foods, medicines, insect bites)
List any special health problems that we should keep in mind in the education of this child:
Names of persons, other than parents, authorized to take above-named child from pre-school. (Picture diriver’s license identification required for pickup.)
Parents will be required to fill out a health care summary and immunization record for each child attending pre-school. Immunization documentation must be available and accurate on the first day a child is in attendance. Families of Preschool registrants agree to a minimum enrollment of two trimesters. Parents must give a two-week written notice when withdrawing a child.
Do you agree? Name Date (MM/DD/YYYY)
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111 Central Ave. North P.O. Box 189, Richmond, MN 56368
Phone: 320-597-2565
Fax: 320-597-4385
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