CUMC NURSERY SCHOOL

Central United Methodist Church Nursery School Program

3 year Olds

MUST BE 3 BEFORE SEPTEMBER 1st.

Child’s First Name_____________________________________________________

Child’s Middle Name__________________________________________________

Child’s Last Name_____________________________________________________

Date of Birth_________________________________________________________

Right or Left handed?__________________________________________________

Any known allergies? Please list and reactions for each_______________________

 Mother’s Full Name___________________________________________________

Father’s Full Name____________________________________________________

Home Address_______________________________________________________

Home Phone_________________________________________________________

Parent Email Address__________________________________________________

Mother’s Cell Phone___________________________________________________

Father’s Cell Phone____________________________________________________

Work Number____________________Is it ok to call work if necessary? YES or NO

How Did you Hear About Our Nursery School?__________________________________

**ALL CHILDREN MUST BE POTTY TRAINED TO ATTEND***

NON-refundable registration fee of $35.00 is due with this completed application.

Please make checks payable to Central United Methodist (CUMC) Preschool

Mail to:  Central United Methodist Preschool

                   Attention 3 year Program

                    205 11th Street

                    Honesdale, PA 18431