Mt. Chestnut Christian Preschool

Student Registration 2011-2012

•  Butler, Pennsylvania 16001

724-287-8799 Preschool  •  724-287-7601 Church

www.mtchestnutchurch.com  •  mccpreschool@zoominternet.net

Child’s Last Name    __________________________________   First Name _______________________________________

Name Child Prefers to be Called _____________________________________________________________________________

Date of Birth _______ / _______ / _______     Age ___________        Male / Female  (circle one)

► Child must be age 3 by September 1^st and must be potty trained.

Home Address ________________________________________________________________________________________________

City _______________________________________________________ State ____________________ Zip ____________________

Parent/Guardian Information:

Father’s Name __________________________________     Mother’s Name ____________________________________

Address _________________________________________    Address ____________________________________________

Home Phone ____________________________________ Home Phone _________________________________________

Cell Phone ______________________________________    Cell Phone _________________________________________

Father’s Occupation ____________________________     Mother’s Occupation _______________________________

Work Phone ____________________________________ Work Phone _______________________________________

Father’s Church Affiliation                                                    Mother’s Church Affiliation

___________________________________________________     ______________________________________________________

Marital Status ___________________________________   Marital Status ______________________________________

(This will help during discussions on families.)

Other Children in Family:

Name ___________________________________________     Date of Birth ______________________________________

Name ___________________________________________     Date of Birth ______________________________________

Name ___________________________________________     Date of Birth ______________________________________

Other Family members living in child’s home:

In case of an emergency and we are unable to reach either parent, please contact:

(These names are to be for LOCAL individuals, whom we have permission to release your child to.)

1.  Name ____________________________________________________________________________________________________________

   Address ________________________________________________ City ___________________________________________________

   Phone __________________________________________________ Cell Phone ____________________________________________

   Relationship to Child ____________________________________________________________________________________________

2. Name ___________________________________________________________________________________________________________

   Address ________________________________________________ City ___________________________________________________

   Phone __________________________________________________ Cell Phone ____________________________________________

   Relationship to Child ____________________________________________________________________________________________

3.  Name____________________________________________________________________________________________________________

   Address ________________________________________________ City ___________________________________________________

   Phone __________________________________________________ Cell Phone ____________________________________________

   Relationship to Child ____________________________________________________________________________________________

In the event of an emergency and the parents cannot be contacted, do you permit your child to be

transferred to Butler Memorial Hospital?        YES _________________   NO ___________________

Other instructions __________________________________________________________________________________________________

Please note any allergies or health problems we should be aware of _________________________________________

A $25.00 Non-refundable registration fee must accompany this application, along with the 1st month's tuition (September) is also due upon registration.

 Please list your 1^st and 2^nd class choices.  Minimum enrollment of 50% is required per class to remain open.  Classes may be closed at the discretion of Mt. Chestnut Presbyterian Church. Any lass cancellation will be announced by July 15th, 2011.

             3 Year Old Classes                                                            4 & 5 Year Old Classes

          Tuesday & Thursday Morning                                                         Monday & Wednesday

              9:30am to 11:30am   $70 p/mo                                                 12:30pm to 3:00pm  $100 p/mo

           Tuesday & Thursday Afternoon                                             Monday & Wednesday Thursday

              12:30pm to 2:30pm   $70 p/mo                                              9:00am to 11:30am   $75 p/mo    

1^st  Choice _____________________________________        

2^nd Choice _____________________________________      Date _________ / _________ / _________     Check # ____________ Amount $ __________