2019-2020 School Year
Application/Registration Form

(Please read carefully & fill out completely!)

Child Information

Child’s Name: (First, Middle, Last)      	
Nickname if applicable:       

Date of Birth:       	Date of Enrollment:      

Gender:      	Race:  	     	Religious Affiliation:        Parish/Church:       

How did you hear about our program? (Dropdown menu) 

Family Information

Mother’s Full Name         Email:       

Father’s Full Name:         Email:       

Parents are: (Dropdown menu)  

Child’s Home Address*: Street address      

City       State       Zip     

Home Phone:       Mother cell:       Father cell:       

*If parents are separated, please provide the address of other parent or legal guardian:

Address:       
		Street					City		State			Zip

Phone:          

The above address belongs to (dropdown menu):  

•	Name of person (if not parent) who has legal custody of child:       

                   Relationship to child:       

Mother’s Employer:       

Address of Employment:       
				Street				City		State			Zip

Mother’s Work Phone:         Cell:       

Father’s Employer:       

Address of Employment:       
				Street				City		State			Zip

Father’s Work Phone:           Cell:       

Siblings:	Name  	          Date of Birth       

		Name  	          Date of Birth       

		Name  	          Date of Birth       

		Name  	          Date of Birth       

Name  	          Date of Birth       

Emergency Information

In case of an emergency, parents will be notified immediately.  If neither parent can be reached, please call:

 Name:       	Relationship   	     

Address:       
		Street					City		State			Zip

Home Phone:           Work Phone:        

Cell:       

 Name:       	Relationship   	     

Address:       
		Street					City		State			Zip

Home Phone:         Work Phone:        

Cell:       

Authorized Pick-up

We will NOT release your child to anyone without authorization from a parent or guardian!

	The following individuals have my authorization to pick up       Child’s name
	from Saint Bernard Preschool:			    

		1.     		2.      		3.     

		4.      		5.      		6.     

	The following individuals are specifically DENIED permission to pick up my child:

DENIED PICK-UP 1.      		
DENIED PICK-UP 2.      

Parent’s signature:  ________________________(Print and sign)	Date:  ________________

Emergency Medical Authorization

In case of an accident or serious illness, I request that Saint Bernard Preschool contact me.  If I cannot be reached, I hereby authorize Saint Bernard Preschool to make whatever arrangements the circumstances allow.

It is understood and agreed that Saint Bernard Preschool, St. Bernard Catholic School, the teachers, nor the Catholic Diocese of Evansville is the insurer of my children’s health and safety while they are at school or engaged in school-supervised activities.  I understand it to be my obligation to provide such insurance as I may desire to purchase to protect myself and my children against the costs of sickness or injury.

If the above named child(ren) needs emergency medical treatment, and neither a parent nor the designated family physician can be contacted, consent is hereby granted for such emergency treatment as may be considered necessary in the opinion of the attending physician. 

														
	Mother or Guardian’s Signature	          Date		Father or Guardian’s signature		Date

Child’s Physician:       Phone:       
Address:       

Child’s Dentist:            Phone:       
Address:       

Child’s Medical Allergies:       

Child’s hospital preference      

Registered Ministry Parent Notice

I understand that Saint Bernard Preschool childcare ministry is not licensed under the laws of Indiana.  However, I understand that this childcare ministry complies with the State rules concerning sanitation and fire safety for the primary use of the structure in which it is conducted.  I understand that it is my responsibility to ensure that the nutritional and health needs of my child are met while my child is at the childcare ministry.

This notice does not absolve the childcare ministry from liability for injury to a child while the child is at the childcare ministry if the cause of the injury is negligence or intentional wrongdoing on the part of the childcare ministry or an employee of the childcare ministry.

Name of child enrolled:  								

Parent’s signature:  							Date:  					

Discipline Policy

The Discipline Policy of Saint Bernard Preschool is as follows:

Absolutely NO corporal punishment will be used to correct a child for misbehavior.  Punishment will also never relate to eating or toilet needs.  The child will be instructed on proper behavior in a civil tone of voice.  If the child continues an inappropriate behavior pattern, he or she will be instructed to sit down for a period of time determined by the incident.  If the child will not accept this discipline, the Director or Administrator of the Center will guide the child by the hand to the Preschool office until he or she agrees to obey the rules of the Center.

Repeated incidents of misbehavior or a child’s continued belligerence, aggression, or violent behavior could result in the child’s dismissal from Saint Bernard Preschool.  Parents will be informed of your child’s negative behavior in the form of an Incident Report, which is to be signed by the parent upon pick-up of the child.  This report will be placed in the child’s file.  Your support and follow up with your child is recommended.  Every child will be treated in the same manner.

Individual rooms/teachers may incorporate her or his own Discipline Cycle to be used for less major infractions of the rules.

Corporal punishment (hitting or spanking) by a parent is NOT to be used on any child on the premises of the St. Bernard Catholic School or St. Bernard Church.

Any questions concerning the Discipline Policy should be directed towards the Director.

I have read and understood this Discipline Policy and agree to adhere to it.

Parent’s signature:  							Date:  					

Transportation Policy – Saint Bernard Preschool

Saint Bernard Preschool serves children ages 3-5. 

Children will walk as a class to the library, as well as occasional walking trips around town for various lesson plans and activities. Whenever walking, the classes will utilize walking ropes or the buddy system and be supervised by teachers and adults to ensure safety.

Saint Bernard Preschool will offer bus transportation only to those students residing in North Spencer County and contracted to ride the bus to and from school each day. These students will ride our Saint Bernard Bus 1, a bus which is owned and operated by Saint Bernard Catholic School, and a 5-point-harness restraint will be provided for each North Spencer preschool student who rides this bus.

I have read and understand the transportation policy of Saint Bernard Preschool. 

		Parent/Guardian Signature						         Date

Permission to walk with class

My child has permission to walk, with his/her class or designated group, to the library, park, uptown and other general locations within the City of Rockport during the 2019-2020 school year. I give my approval for my child’s participation in the event and agree to assume all risks and hazards incidental to the conduct of the event. I do further hereby waive, release, absolve, indemnify and hold harmless the Bishop of the Catholic Diocese of Evansville, Saint Bernard Parish, Saint Bernard School, Fr. Ron Kreilein (Pastor) and any of their respective affiliates, successors, agents, employees, members and representatives, adult sponsors and other volunteers involved with the event from any and all claims, including claims of personal injury to my child or property damage, under any theory of law (including negligence, but not reckless or intentional conduct) in any way resulting from or arising in connection with the event and/or transportation to and from the event.

		Parent/Guardian Signature						         Date

Consent to Photograph

I give consent for my child to be photographed or video taped while participating in everyday, supervised school activities.  These may be published in the newsletter, local newspaper, or school web page or social media. No photos used on the parish/school website or social media sites will identify the student by full name.

														
		Parent/Guardian Signature						         Date

Playground

My child has my permission to play on the Saint Bernard School playground. I understand that this playground is not fully fenced in, and I also understand that some of the equipment on the playground is rated for students aged 5-12 years. I understand that children will be well supervised and measures have been taken to ensure the safety of all children at play.

		Parent/Guardian Signature						         Date

Parent Handbook Acknowledgement

I,      (name of parent), parent of      (name of student), who is enrolled at Saint Bernard Preschool, acknowledge that I have reviewed the 2019-2020 Parent Handbook.  

I have read and understand the policies of Saint Bernard Preschool and will follow them while my child attends the Saint Bernard Preschool in Rockport, Indiana.

														
		Parent/Guardian Signature						         Date

SUSPENSION AND EXPULSION POLICY 
(A copy of this policy appears in the parent handbook)

Unfortunately, there may be occasions that could warrant the expulsion of a child from our program either on a short-term or permanent basis. We want to do everything in our power to prevent this from happening. Most children respond well to positive discipline and re-direction. Our primary goal, however, is to ensure the safety of ALL of our children. The following are some of the ways we will work to ensure that behavior challenges are addressed in an appropriate way in order to attempt to avoid expulsion.

1.	Staff will use many methods to help calm a child who is being disruptive. These methods include but are not limited to: re-direction, positive approaches and language, offering choices, consistently applying consequences and rewards, and giving verbal warnings when none of the above actions are helping.
2.	When children are upset or having difficulty adjusting to expectations, they will be allowed to move to a designated quiet space in the classroom until they are ready to re-join the class activity. Staff will explain the reasons for the quiet space and allow students to choose this option to help them re-gain control of their own emotions or behaviors.
3.	Staff will model appropriate behavior to students to help them get along well with their peers. Staff will help students engage in a variety of activities designed to help them learn to express their feelings in healthy, safe ways so that all students can feel supported emotionally.
4.	Staff will receive annual training on developmentally-appropriate behaviors and positive approaches to classroom management. This training will seek to help staff recognize the difference between developmentally-appropriate behavior challenges and behaviors that could pose a larger concern or threat to the learning environment and safety of the children.
5.	If disruptive behavior continues after several attempts at correction, the behavior will be confidentially documented and communicated to parents.
6.	The Director, Teacher, and Parent/Guardian will schedule a conference to discuss how to promote positive behaviors in class, including trying to implement any solutions that may have been useful at home. Staff will communicate with parents about possible options for intervention, including referral to our school counselor or behavior specialists who might offer some assistance.
7.	The Staff will work with parents to create a plan and timeline for behavioral change, which will be confidentially documented. The plan and timeline will be specific to the situation, the needs of the child in question, and the severity of the behavior. Staff and parents will schedule regular conferences, specific to the plan timeline, to review progress that has been made and make any necessary changes to the plan.
8.	If the above actions have not resulted in appropriate change in the child’s behavior, and if the child has become a danger to him/herself or to others in the classroom, the child’s parent/guardian will be advised verbally and in writing of the necessity of suspension or expulsion. The parent/guardian will be informed of the length of the suspension and behavioral changes required for the child to re-enroll. The option to suspend or expel a child will be used as a last resort, only after all other options have been exhausted, or if the child’s ongoing presence in the classroom poses a significant threat to the well-being of him/herself or to others.
9.	Any situations requiring intervention will be under review at the end of each school year so that staff can learn from the experiences and gain knowledge about how to better address behavioral issues with future classes.
***************************************************************************************
I have read and understand the suspension and expulsion policy of Saint Bernard Preschool and will abide by its terms.

Parent Signature_________________________________________Date_________________________
Helpful Information About Your Child

Family Information

If the child has siblings, do they live with your child?     		

Does anyone other than parents and siblings live with your child?     		

	If yes, please list and indicate who and their relationship to your child:       

Is there anything about your family that would be helpful for us to know to help care for your child or 

understand his or her behavior?       

Personal History

Is your child right-handed or left-handed?      

Has your child been cared for by anyone other than parents?      
Has your child had a previous group, daycare or preschool experience?      

If yes, when and where?       

Does your child have any allergies?       If yes, what are they?       

What medical, health, special needs, or handicap information should we know about your child?       

Does your child take any medication regularly?           If yes, what is the medication and what is it 

for?       

Are there any special food or eating instructions for you child?         If yes, what?       

Are there any particular sleeping or napping needs for your child?  	        If yes, what?       

What words does your child use for toileting?       

Does your child use the restroom independently?     		

Does your child have any bowel or bladder irregularities?       If yes, please explain       

What time does your child:   Go to bed?       	Get up?       

Does your child normally take a nap?	       	What time of day?         How Long?       

Does your child have a special item to nap with?         If yes, what?       

What is your child’s routine in preparation for sleeping/rest time?       

Does your child have any major fears, such as storms, dark, etc.?           If yes, what?       

Other Miscellaneous Info

Do you have any pets?           If so, what kind?       

What are your child’s favorite play materials?       
	
What are your child’s favorite foods?       

What particular food does your child dislike?       

Are there any discipline problems at home?  	     If yes, please explain       

How are discipline problems handled at home?       

Please use this space for any additional information, such as child’s communication, comforting, etc., about your child that may help us to know your child and care for him/her well.     

Any other comments:       

I would like to register my child for the following program for the 
2019-2020 school year: 
Saint Bernard Preschool and PreKindergarten programs operate on a school schedule. Programs are open when Saint Bernard School is open.

1	PreKindergarten (For students who may attend Kindergarten the following year)
Full Time, Monday through Friday
6 a.m. – 6 p.m. care, PreK instruction 7:45 a.m.– 2:45 p.m.
Rest period in the afternoon
Tuition:	 $385 per month for ten months (August – May)

1	PreKindergarten morning class only
7:45 a.m. – 10:45 a.m.,  Monday through Friday
Tuition: 	$205 per month for ten months (August – May)

1	PreKindergarten afternoon class only
12:00 p.m. – 3:00 p.m.,  Monday, Wednesday, and Friday
Tuition: 	$125 per month for ten months (August – May)

1	Preschool - Age 3-4 and potty trained
Full Time, Monday through Friday
6 a.m. – 6 p.m. care, Classroom instruction 7:45 a.m. – 2:45 p.m.
Naptime in the afternoon
Tuition:	 $385 per month for ten months (August – May)

1	Preschool Part-Time morning class only 
7:45 a.m. – 10:45 a.m.
Monday, Wednesday, and Friday
Tuition: 	$125 per month for ten months (August – May)

1	Before School Care – 
charges apply only to morning-only Preschool or PreK students who arrive before 7:30 a.m.
Fee:	$2.00 per day

Child Care Fee Contract

The childcare fee for my child has been determined to be  per month.  I understand that payment is due by the 20th day of each month.  I understand that I will be charged for care of my child(ren) according to the agreed upon schedule and the policy stated in the Parent Handbook.  I will keep charges paid in accordance with the policies established by Saint Bernard Preschool.  It is my responsibility to contact the Administrator should I fall behind in payment or if there is to be a change in my child’s schedule.  Non-payment can lead to my child’s dismissal from the program.

Parent’s Signature  ________________________________		Date  ___________________