Mt. Vernon Baptist Church Registration Form

School Year *

Student Status *

New Student
Returning Student

Referred By

First

Last

Starting Date *

Student Information

Name *

First

Last

Gender *

Male
Female

Date of Birth *

School Grade Applying For *

Ethnicity *

Pursuant to the Internal Revenue Service (IRS) regulations, Mount Vernon Baptist Church Preschol is required to file an Annual Certification of Racial Nondiscrimination (Form 5578). Identification is requested but not required.

Has your child previously attended a preschool/daycare or school? *

Yes
No

If yes please list school information:

Preschool/Day Care Center or School, City/State, Phone, Year

Please list any dismissals from any schools for academic or behavioral issues

How do you hear about our schools? *

Website
Flyers
Drive-by
Referred by

Parent / Guardian Information

Parent One *

Parent One, Other Please Specify

Name (Parent One) *

First

Last

Address (Parent One)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone (Parent One) *

Cell Phone (Parent One)

Work Phone (Parent One)

Email Address (Parent One)

Employer and Occupation (Parent One)

Do you regularly attend church? (P1)

Current Church Membership, Pastor's Name and Phone # (P1)

If No, about how many times do you attend yearly? (P1)

Parent Two *

Parent Two, Other Please Specify

Name (Parent Two) *

First

Last

Address (Parent Two)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone (Parent Two) *

Cell Phone (Parent Two)

Work Phone (Parent Two)

Email Address (Parent Two)

Employer and Occupation (P2)

Do you regularly attend church? (P2)

* Only necessary to complete if different from Parent One

Current Church Membership, Pastor's Name and Phone # (P2)

If No, about how many times do you attend yearly? (P2)

Does the child named above currently reside with both biological parents? *

Yes
No

Child currently resides with________________ ___ as noted per child’s physical address of residence

If no, please provide below who the child resides with and understand that this document confirms that the section on “Student’s Information” is accurate and must be updated whenever a change occurs while the child is enrolled at MVBCP.

and the relationship to the above child named is/are his/her

Is there a court order signed and sealed by a court appointed judge regarding custody of the above child? *

Yes
No

If yes, a copy of the most current order must be in the child’s file. If an order is in place, and a biological parent who is not allowed to pick the child up, the appropriate authorities must have the order presented to them or the authorities will allow the parent who is not on the order to take the child if they can prove that he/she is the biological parent. A copy of a current order is critical to have in the child’s file, in the event proof must be shared with authorities if the unauthorized parent attempts to pick up.

Medical Data

Allergies *

My child is allergic to the following medications

Physician Name *

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Medication Child is taking *

Last Tetanus Shot *

Outstanding Medical History (i.e., Diabetes, Heart Disease, etc.)

Insurance Information

Insurance Company: *

Plan Number

Group Number

Hospital

Subscriber's Phone

Spouse

Spouse's Phone

Financial Information

**Please indicate who is responsible for all financial obligations to MVBCP:

Name *

First

Last

Relationship

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Are there any outstanding financial obligations for this student at any other preschool or daycare? *

If yes, please indicate name and address of school:

By marking this YES to this checkbox, the Parent/Guardian agrees that this is a legally binding contract. *

Yes
No

Captcha *

=

Registration Form

Student Information

Parent / Guardian Information

Medical Data

Insurance Information

Financial Information

Address

Email

Call

Map