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Shiners' Club Preschool
Registration Form 2024--2025
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* Indicates required question
Email
*
Your email
Today's date
*
MM
/
DD
/
YYYY
Which class are you registering for? No registration fee required.
Preschool Club
PreK Club
Clear selection
Have you received and read the General Information flyer?
*
Yes
No
Child's Full Name
*
Your answer
Name Child Goes By
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
Your answer
Boy or Girl
*
Boy
Girl
Address
*
Your answer
Phone Number
*
Your answer
Preferred Email Address
*
Your answer
Mother's Name
*
Your answer
Mother's Phone Number
*
Your answer
Mother's Address (if different from child's)
*
Your answer
Father's Name
*
Your answer
Father's Phone Number
*
Your answer
Father's Address (if different from the child's)
*
Your answer
Child's special interests and activities
*
Your answer
Is you child right or left-handed?
*
Right-handed
Left-handed
Not sure yet
Any allergies?
*
Your answer
Persons authorized to pick up child (other than parents listed above)
*
Your answer
Emergency Contacts (please list 2)
*
Your answer
Are there any concerns of
*
Hearing loss or difficulties
Vision difficulties
Speech difficulties
Other... We will talk so you can share your concerns.
None
By checking below you are committing to pay the monthly payment listed using PayPal for 9 months for the 2024-25 school year.
*
Preschool Club (monthly payment of $144)
PreK Club (monthly payment of $216)
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