Pied Piper School Registration Form

Fall 2020 – June 2021

Child’s Name ________________, _______________________ Last First

Age in September _______ Years _______ Months

Birthday _______ Month ________ Day _______ Year

Address ______________________________________________ Street

______________________________ _______________ Town Zip Code (Not Mom & Dad) Home Phone ________________ Emergency #1 _______________ Family Doctor _______________Emergency #2 _______________ Phone Number_______________Emergency #3 _______________

Cell Phone (Mom)_____________Cell Phone(Dad)________________

Mother’s Name________Employer _________Phone #__________ Father’s Name________ Employer_________Phone #__________ Primary Email:____________________________________

Previous Pre-School Experience ____________________________ Age & Name of Siblings __________________________________ School District your child will attend_________________________

Any fears or inhibitions that the school should be aware of? _____________________________________________________ Any allergies, medical problems, special medications or food restrictions ? __________________________________________ Does your child have an Epi-Pen?(circle one) No Yes Special interests, toys or concerns ?________________________ ___________________________________________________

2020-2021

Who will provide transportation for your child? #1. _______________________ Phone Number_____________ #2 _______________________ Phone Number_____________ #3. _______________________ Phone Number_____________

Specify (Circle) days and sessions you would like your child to attend.

*************** Only ONE (1) discount can be applied per family!*************** Sibling Discount: 10% discount for second or more children currently enrolled in

the program Parent Alumni Discount: 10% discount for the child of any Pied Piper Alumni!

Insurance fee: $100.00 per child insurance fee due with registration form. *ALL Insurance fees and tuitions paid are Non Refundable.

Diapering Fee: If your child wears diapers there is a $20 per month charge for extra staffing and wipes.

*Ask about pricing for regular use to get a reduced price on Monthly Tuition.

AGREEMENT: I consent to the enrollment of my child in the Pied Piper school and agree to pay the monthly tuition on the 1st of each month. Any payment made on or after the 15th of the month is subject to a $15.00 late fee. I understand tuition is due for the entire school year (September to June). June 2021 tuition is due in September to be held in the event you are unable to complete the year. If you do not give the school a 1 months notice, this security money will be retained. I give consent for my Pre-K child to leave PIED PIPER School to take part in monthly field trips. In case of accident, I agree that emergency medical care may be given in the event the person/persons designated above cannot be reached. I give Pied Piper permission to use my child’s picture in brochures, press releases or online website. I have attached my child’s health packet to this registration form. I agree to hold Pied Piper harmless for liability or claim of injury, illness or accident suffered by the above child as result of enrollment, attendance, or participation in activities at Pied Piper.

I have attached my child’s packet(Immunization/Medical Records, Blue Card, Napping Agreement, Protection Policy, Potassium Iodine Form) to this registration form.

Parent/Guardian Signature _________________________ DATE ________

Days Per

Week

Specify Days Half Day AM / PM 9-11:45 or 12:15-3

Full Day 9-3pm

Daycare 8-5pm

Extended Care

7-6pm

Random Day

As Needed *If Available —>

$40 $65 $80 $90

2 T TH $281 $482 $633 $6803 M W F $359 $608 $842 $9123 T TH F $359 $608 $842 $9125 M T W TH F $522 $860 $1105 $1220

Emergency Daily Add-On

Lunch Bunch

7am Drop-off

8am Drop-off

Pickup at 4pm

Pickup at 5pm

Pickup at 6pm

Random Day $20 $15 $10 $10 $15 $20