2012-13 PReP Preschool Registration

Please complete both sides and mail or drop off at: PAIIR, 201 8th St NW, Rochester, MN 55901. Call PAIIR at 328-4020 if you have any questions. PARENT INFORMATION
Parent/Guardian Name(s): Last/First

Home Address

Please provide at least 2 phone numbers where we can contact you. Home Phone Cell Phone

Work Phone

E-mail address (required)

EMERGENCY CONTACT INFORMATION Emergency Contact Name Emergency Contact Relationship to family

Emergency Contact Phone Number

Emergency Contact Alternate Phone Number

STUDENT INFORMATION / CHILD ATTENDING CLASS: Please ll out a separate registration for each child attending.
Childs Name: Last/First Gender Birth Date M/D/YR Language spoken at home:

THE RACIAL/ETHNIC BACKGROUND OF YOUR CHILD: Please circle one.

White

Black/African/African Amercian

Hispanic or Latino Other, single race

Asian

Native Hawaiian or Other Pacic Islander

American Indian/Alaskan Native

Please list any allergies:

Other, two or more races

Please list any medication given regularly:

Please note any special needs, health or developmental concerns, or support services child is receiving, including Early Childhood Special Education:

Has your child participated in an Early Childhood Check-In/Screening? (Please circle one.) If yes, where and when?

YES

NO

Where/Organization:

When? (month/year)

CLASS INFORMATION

Choice

Class title

Location:

Parent day:

Class days:

Time:

Hours/week

Explorers Discoverers Voyagers Pathnders Adventurers Trailblazers

Churchill (tentative) Tuesday Northrop Hoover (tentative) TBD Northrop Northrop Monday Monday TBD Tuesday Monday

T/TH M/W M/W/F M/T/W/TH T/TH M/T/W/TH

9:00 - 11:30 AM 5:30 - 7:45 PM 12:45 - 3:15 PM 9:00 - 11:30 AM 5:30 - 7:45 PM 12:30 - 3:30 PM

5 4.5 7.5 10 4.5 12

ADDITIONAL ATTENDANCE INFORMATION

PARENT PARTICIPATION: I understand that participation in PRePs weekly parent education is a requirement of the PReP Preschool program.

Signature of parent/guardian attending: Name of parent/guardian attending: (please print.)

date

SIBLING CARE INFORMATION - LIMITED care may be available at some locations for siblings on the Parent Day while parent/guardian is in class with enrolled child.

Does parent/guardian have younger children that will need care during class on the Parent Day? YES
Siblings Name: Last/First Gender Birth Date M/D/YR Allergies/Special Needs

NO

PREP PRESCHOOL FINANCIAL INFORMATION

DEPOSIT: PAIIR does not charge a registration fee; however, a $50.00 non-refundable deposit is required with your childs registration. A second $50.00 non-refundable deposit is required by June 1, 2012 to continue to hold your childs spot in the program. Both deposits will be applied toward your May 2013 tuition payment. TUITION PAYMENTS: Monthly tuition payments are due the 15th of the month for the following month. (Example: Your September tuition payment is due on August 15, 2012.) Sibling care is available for an additional fee. FINANCIAL ASSISTANCE: Limited nancial assistance is available for families who qualify. Please indicate below if you would like information on nancial assistance. Please send me information regarding nancial assistance:
PAYMENT DUE WITH REGISTRATION

YES

NO $50.00 $50.00

FIRST DEPOSIT: Minimum due with registration form is $50.00 > SECOND DEPOSIT: Due June 1. If the current date is on or after June 1, please add $50.00 here: > TUITION & sibling care: If registering on or after August 15, your 1st months fees are due: Please add it here:> TOTAL DUE with registration: >
PAYMENT INFORMATION

CASH ENCLOSED: $ CHECK #

credit card type: credit card #

$
expiration date

MC VISA AMEX

signature: