Timson Hill Preschool Application

Along with completing this form, a $25 application fee is required if seeking to attend THP for more than 10 hours (Act 166 Funds cover 10 hours of Pre-K for Vermont Residents). Please mail the application fee to: Timson Hill Preschool, P.O. Box 149, Williamsville, VT 05362.

Applicant Information

Child's Name *

Date of Birth *

YYYY

Pronouns *

Race *

Language(s) Spoken at Home *

Sibling Name(s), Pronouns & Date of Birth *

Please indicate your preference for number of program days and preferred schedule below:

5 Days (M-F)

3 Days (M,T,W)

2 Days (Th, F)

Other

Morning program (8:30 - 12:00)

Afternoon Program (12:00 - 3:30)

Before School Care (7:30 - 8:30)

After Care (3:30 - 4:30)

Clear selection

If you selected "other" above, please explain:

$25 Application Fee is in the mail

Yes

Clear selection

Parent/Guardian #1

Name *

Pronouns *

She/Her

He/His

They/Them

Other:

Address *

Home Phone *

Email *

Place of Work *

Work/Cell Phone *

Parent/Guardian #2

Name *

Pronouns *

She/Her

He/His

They/Them

Other:

Address - if different from above

Home Phone - if different from above

Email *

Place of Work *

Work/Cell Phone *

Name up to three family members/friends (other than parents/guardians) who have permission to pick up. Please include full name, relationship to child, and their phone #, e.g. First Last, Grandmother, 777-777-7777

Emergency Information

Child's Doctor Name *

Child's Doctor Phone Number *

Child's Dentist Name *

Child's Dentist Phone Number *

Name of Hospital you would prefer you child to receive care: *

Life-Threatening Allergies *

Bees/Wasps/Hornets

Tree Nuts

Peanuts

Shellfish/Fish

N/A

Other:

Required

Does your child require an epi-pen? *

Yes

Emergency Contacts

If the parent/guardians are not available, who should we contact, in order of priority?

Emergency Contact # 1 Name *

Emergency Contact #1 Relationship to Child *

Emergency Contact #1 Phone Number *

Emergency Contact # 2 Name *

Emergency Contact #2 Relationship to Child *

Emergency Contact #2 Phone Number *

Emergency Contact # 3 Name *

Emergency Contact #3 Relationship to Child *

Emergency Contact #3 Phone Number *

By typing my name below, I authorize the staff of Timson Hill Preschool to administer medical treatment for my child in the case of a medical emergency when/if I cannot be reached. I also authorize the staff of Timson Hill Preschool to contact an ambulance when considered necessary for my child, in the case of an emergency and I cannot be reached.

Parent authorization (type name below & date)

I give permission for the staff of Timson Hill preschool to give/apply the following non-prescription medication and or protectants if necessary:

Yes

First Aid Cream

Sunscreen

Insect Repellent (DEET Free)

Parent Name & Date authorizing above permission

Getting to Know your Child...

Please list any fears your child may have that we should be aware of. *

Does your child have any health problems we should be aware of? *

Does your child have any allergies? Please describe: *

Does your child have any sleep issues? Do they nap? Please describe: *

Does your child take any medications on a regular basis? Please list: *

Does your child have any dietary needs? Vegetarian? Please list: *

Are there any other concerns or comments about your child that you think would be helpful to the school to know? *

Are there any special beliefs/culture in your family that we should be aware of? *

Who lives in the child’s house? Include pets: *

What holidays do you celebrate? *

Does your child use the toilet on their own? *

Thank you for your interest in Timson Hill Preschool. Please make a copy of this form for your records. Once accepted, you will receive a parent handbook, contract, and annual permission slips. A School Calendar and other relevant information will be sent home.

A deposit of $100 will be due upon acceptance to the program to finalize your registration. All deposits will be applied to your school account in June 2022 once all school fees and contract obligations have been fulfilled.

Please provide a copy of your child’s most recent physical, immunization records, and insurance card upon acceptance into the program.

If you have any questions, please contact the director or any board member. Thank you for your interest in Timson Hill Preschool. We look forward to a successful year learning and growing with your child!

Timson Hill Preschool is an equal rights institution, and does not discriminate against any person based on race, national origin, creed, faith, mental or physical challenges, or sexual orientation.

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