Registration packet

Spumc Weekday school

Dear Parents,
Please take the time to fill out the 2012-2013 registration packet,
submit it with your $55.00 registration fee and applicable activity
fee (fees differ for each class) to hold your childs place in the
Weekday School. Open spaces are filled on a first come, first
served basis. In order to assure your childs 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 childs age must correlate with the
appropriate class.
We look forward to a wonderful year!
The Weekday School Board of Directors
Weekday School Staff
South Point United Methodist Church

SPUMC Weekday School

2011 2012 Payment Guidelines
Class

Registration Fee

Activity Fee

(non-refundable)

(non-refundable)

Monthly Tuition

PMO

$55/ school year

$0

$60/ month

2s

$55/ school year

$20/ school year

$105/ month

3s
(2 day)

$55/ school year

$40/ school year

$115/ month

3s
(3 day)

$55/ school year

$45/ school year

$135/ month

4s
(3 day)

$55/ school year

$55/ school year

$135/ month

4s
(5 day)

$55/ school year

$55/ school year

$175/ month

To confirm your childs 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 and 4s) for your child and a monthly
subscription to Scholastic magazine (4s).

I am registering my child for the:

PMO Program
2 year-old class
3 year-old class (2 days)
3 year-old class (3 days)
4 year-old class (3 days)
4 year-old class (5 days)

___________________
___________________
___________________
___________________
___________________
___________________

Childs Name ____________________________________________________________

(First)
(Middle)
(Last)
Name your child prefers to be called __________________________________________
Childs Birth date _______________________________ Childs Age _______________
Parent or Guardians Name _________________________________________________
Address ________________________________________________________________
Home Phone _________________________ Work/ Cell Phone ____________________
E-Mail Address __________________________________________________________
Parent or Guardians 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: ___________________
T-shirt Paid: __________________________(Amt)
Date: ___________________

Add t-shirt pai

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
DTP/DT
Polio
HiB
Hepatitis B
MMR
Chicken Pox
Prevnar
Other

#1

#2

#3

xxxxxxxxxx

#4

#5

xxxxxxxxxx
xxxxxxxxxx

xxxxxxxxx
xxxxxxxxx
xxxxxxxxx
xxxxxxxxx

_________________________________________
________________________
Physicians Signature

Date of Examination

_________________________________________
________________________
Office Address

Telephone Number

5
Childs 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 childs physician and other persons listed for emergency
contact.
______________________
__________________________________________
Date
Signature of parent or guardian

SPUMC Weekday School

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

_____

Childs Name
Class
Parents Name
Signature
Date

__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

Emergency Contact Information

To be kept in Emergency Contact Folder

_____

Childs Name __________________________________________________

Phone Number ________________________ Birth Date _______________
Address ______________________________________________________
_____________________________________________________________
City
State
Zip Code
Mothers (or Legal Guardian) Name ________________________________
Daytime Phone Number _________________________________________
Other Contact Numbers __________________________________________
Fathers 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 _____
_____________________________________________________________
_____________________________________________________________

SPUMC Weekday school t-shirts

We ask that each child in the 3 and 4 year-old 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

__________ x

Circle size ordered

$10/ SHIRT

Number of shirts

SHORT SLEEVE SHIRT ADULT:

XS

XL

XXL

__________ x

Circle size ordered

Number of shirts

TOTAL:

____________

$12/ SHIRT

$__________