admin@mtvernonbc.org
Call Us (703) 979-1558
935 23rd Street South Arlington, VA 22202
Tap to Call
Facebook
Twitter
Menu
Home
Worship and Directions
Membership
Mailing List
Prayer Requests
Crystal City
Welcome
Our Pastor
Calendar
Coronavirus
Discipleship
Adult Bible Study
Youth Bible Study
Sunday School
Ministries
Justice Formation Fellowship
Make Change
Music Ministry
Youth Ministry
Sunday School
Resources
Giving
Contact Us
Shop
Home
Worship and Directions
Membership
Mailing List
Prayer Requests
Crystal City
Welcome
Our Pastor
Calendar
Coronavirus
Discipleship
Adult Bible Study
Youth Bible Study
Sunday School
Ministries
Justice Formation Fellowship
Make Change
Music Ministry
Youth Ministry
Sunday School
Resources
Giving
Contact Us
Shop
Registration Form
Registration Form
Preschool Enrollment Form
Please enable JavaScript in your browser to complete this 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
*
Early Preschool Part Time
Early Preschool Full Time
Preschool Part Time
Preschool Full Time
Pre-K Part Time
Pre-K Full Time
Kindergarten Part Time
Kindergarten Full Time
1st-3rd Grade Part Time
1st-3rd Grade Full Time
Ethnicity
*
African American
Arabic
Asian
Caucasian
Hispanic
Indian
Native American
Decline to Identify
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
*
Father
Mother
Other
Parent One, Other Please Specify
Name (Parent One)
*
First
Last
Address (Parent One)
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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)
Yes
No
Current Church Membership, Pastor's Name and Phone # (P1)
If No, about how many times do you attend yearly? (P1)
Parent Two
*
Father
Mother
Other
Parent Two, Other Please Specify
Name (Parent Two)
*
First
Last
Address (Parent Two)
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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)
Yes
No
* 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 NOT allergic to any medications
My Child IS allergic to medications listed below
My child is allergic to the following medications
Physician Name
*
Physician Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
Cell Phone
Email Address
Are there any outstanding financial obligations for this student at any other preschool or daycare?
*
Yes
No
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
*
=
Submit