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2. Select Program*

   1. 3 Day (Tuesday/Wednesday/Thursday) | Noon-2:30 pm

   1. 5 Day (Monday-Friday) | 8:30a-11:00a
6. To Complete Registration:

   To secure your child's registration, after completing this form, immediately make your $75 registration payment online.

   
   

10. Child's Name*

    Full Legal Name

11. Date of Birth*
    Date of Birth
12. Age:*
13. Sex*
    -- Select One --FemaleMale
15. Copy of Birth Certificate*
16. Copy of Current Shot/Vaccination Records*
18. Child's Address*
20. City*
21. State*
22. Zip Code*
24. Child Resides With:*

    1. Both Parents
    2. Mother
    3. Father
    4. Guardian
25. Other:
26. Who will be picking up and dropping off your child at school?*

    eg. parent, aunt/uncle, babysitter, grandparent, van rider, etc

30. Parent/Guardian Information
32. Parent/Guardian #1*
33. Email Address*
35. Address*
37. City*
38. State*
39. Zip Code*
41. Primary Phone Number
42. Place of Employment*

    If unemployed/homemaker write "N/A"

43. Employment Phone Number*

    If unemployed/homemaker write "N/A"

45. Parent/Guardian #2
46. Email Address
48. Address
50. City
51. State
52. Zip Code
54. Primary Phone Number
55. Place of Employment

    If unemployed/homemaker write "N/A"

56. Employment Phone Number

    If unemployed/homemaker write "N/A"

60. Persons To Be Notified In Case of An Emergency
62. Person #1 | First and Last Name*
63. Person #1 | Phone Number*
65. Person #2 | First and Last Name*
66. Person #2 | Phone Number*
70. Medical Information:
72. Child's Physician*
73. Phone Number*
75. Are there any special medical conditions or allergies that we should be aware of?*

    1. Yes

    1. No
76. If yes, please explain:
78. If your child on any medication for ADD or ADHD?*

    1. Yes
    2. No
79. If so, please give specifics
83. Payment Information:
85. Who is responsible for preschool payments?*
87. Payment Agreement*

    • Registration/Supply fee is paid in full at the time of registration. (Non-refundable if for some reason you drop out of program)

    • Monthly fees are due by the 27th of each month or a $20 late fee will be charged.

    • Each parent will receive a Preschool Handbook that explains Preschool rules, policies and procedures. Please take the time to read it.

    • By signing below you are responsible for payment.

    1. I agree.
89. Electronic Signature
91. Play Equipment*

    I hereby grant permission for my child to use all the play equipment used in the Preschool Program at the Shelbyville Parks Department and to leave the facility for walks or field trips. I grant permission for my child to be included in pictures connected with the program. I hereby grant permission for steps to be taken for emergency care, if need arises. These steps include attempting to contact the parent, guardian, or alternate person in case of emergency and having a child taken to the emergency room accompanied by a staff person. Any expenses for the emergency care will be the responsibility of the child’s family.

    1. I agree.
93. Electronic Signature
97. The following people MAY pick up my child from school:
99. Contact #1 First and Last Name*
100. Relationship to Child*
101. Contact #1 Phone:*
103. Contact #2 First and Last Name:
104. Relationship to Child
105. Contact #2 Phone
107. Contact #3 First and Last Name
108. Relationship to Child
109. Contact #3 Phone
113. The following people MAY NOT pick up my child from school:

     We must have a photo of those not able to pick your child up from school. 

115. Person #1 First and Last Name
116. Relationship to Child
118. Photo of Person #1:
120. Person #2: First and Last Name
121. Relationship to Child
123. Photo of Person #2:
127. About My Child
129. Child's First and Last Name*
130. Name to be Used & Written at Preschool:*
131. Child's Birthdate*
     Child's Birthdate
133. List Other Siblings And Their Ages:
134. Does your child nap?*

     1. Yes
     2. No
135. When?
137. What time does your child usually go to bed at night?*
138. What time does your child usually wake up in the morning?*
139. What does your child usually eat for breakfast (AM class students) or lunch (PM class students)?*
141. If your child potty-trained?*

     1. Yes
     2. No

     All students must be to attend preschool.

142. Does your child have any problems with hearing or vision?*

     1. Yes- hearing only
     2. Yes- vision only
     3. Yes- hearing and vision
     4. No
143. Does your child have any special fears?

     If none, leave blank. 

     If yes, please specify.

144. Does your child have any speech concerns?

     If none, leave blank.

     If yes, please specify.

146. What are your child's favorite activities?*
147. Please list any languages other than English used in the home?

149. Please note: accommodations for special assistance can be requested by emailing parks@cityofshelbyvillein.com for any programs or events no sooner than two weeks prior to the event date. All requests will be considered to ensure an inclusive and accessible experience for all participants.  

153. Agreement to Compromise Debt
155. Electronic Signature Agreement*

     The Shelbyville Parks and Recreation Department hereby enters into an agreement with the parents of the child enrolled in the Shelbyville Parks Department Preschool Program under the following terms:

     
     

     1.  If a child drops out of the program any time during the school year, the parents are still liable for the remainder of the school year fees.

     2. The parents are also responsible to make sure payments are made each month or they must pay a late fee and the payment.

     3. If for unseen circumstances, the parents cannot make payment; the parents can make arrangements of payments or request a waiver, accompanied by a letter of circumstance.  This letter will be reviewed, and approved or disapproved upon the Director’s discretion.  A follow-up phone call or letter will be sent out with the Director’s decision.

     4. If for any reason the parent does not pay the debt in full, the Shelbyville Parks Department shall have full rights to prosecute for the total amount due.

     
     

     This agreement shall be binding for all individual(s) that sign below.

     
     

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
157. Parent/Guardian #1's Electronic Signature*
158. Date SIgned*
     Date SIgned
160. Parent/Guardian #2's Signature
161. Date Signed*
     Date Signed
Leave This Blank:


163. 1. Receive an email copy of this form.
164. Email address

     This field is not part of the form submission.

165. Submit

* indicates a required field