Student Name *

Student birth date *

Student's Current Grade *

Student's School *

Our School Age Program is only open to the children of Madison Street UMC Staff, siblings of current preschool students, and church members. Does this student meet this criteria? *

Please indicate which criteria you are enrolling under: *

Does the student have any allergies that we need to be aware of? *

Please describe any allergies or health issues that the staff at Madison Street Preschool need to be aware of: *

Parent names: *

Address: *

Phone Number: *

Please list emergency contact name and contact number for anyone we may need to contact (other than parents listed above) *

Do you agree to supply the staff of Madison Street Preschool with all materials and CMCSS supplies that your child will need to complete remote learning school work and/or ZOOM class meetings while your child is in the care of MSP? (Church Wifi will be utilized, so CMCSS hotspots are not needed.) *

By registering your child for our School Age program, you agree that your child will attend Madison Street Preschool on Tuesday & Thursday, January 12/15 and January 19/21, 2021. (If CMCSS remote learning is extended beyond the current return date of January 25, our program will be extended.) Your registration is an acknowledgement of a commitment to pay $40 per week per child for this programming for school age children, as well as a verification that your family acknowledges and agrees to abide by all current MSP and MSUMC COVID-19 protocols and procedures. *