Peace United Methodist Church Preschool

                           801 Maple Grove Dr.; Fredericksburg, VA 22407

School Year: ___________

Child’s Full Name_____________________________Nick Name__________

Date of Birth______________         Sex________

Child lives with______________________________________

Home Address___________________________________Phone___________

city______________State______Zip____________

Father’s Name ___________________________Phone________________

   Cell Phone________________

Employer and Address__________________________________________

 Work Phone________________

Mother’s Name___________________________Phone________________

              Cell Phone________________

Employer and Address__________________________________________

 Work Phone________________

Siblings:

          Name_______________ age_____     Name_______________ age_____

Name_______________ age_____     Name_______________ age_____

Allergies:_____________________________________________________

Health Issues:_________________________________________________

*Is the applicant currently enrolled in Peace Preschool?__________

*Is the applicant a sibling of a currently enrolled student?__________

*Are you a member of Peace United Methodist Church?__________

*Has a sibling attended Peace Preschool in the past?__________

I am aware of the “Peace United Methodist Church Preschool Policy of Enrollment and Withdraw” and agree to abide by it.

Parent Signature:_______________________________________

_____________________________________________________________

Date Received:__________________Registration Fee __________Check #___