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Red Bridge United Methodist Church         For Office Use Only:
Early Childhood Center (ECC)                
Paid ________  Date ___ /___ /___
2017-2018 Registration                                      Check #__________

01 Student Information
02 Family Information
03 Student Profile
04 Class Selection
05 Emergency Contact and Carpool Information
06 Authorization for Emergency Medical Care
07 Health Agreement
08 Acceptance of Terms










Medical Information
This is a non-complete list of the possible developmental delays or medical issues.  We will use this information to help us properly place your child in a classroom.  Please check any and all that apply to your child.









Emergency Contact Information & Carpool Authorization
Those who have permission to care for my child (other than parents or doctor).



Authorization for Emergency Medical Care
I understand I will be notified immediately in case of accident or injury to my child.  If my child requires emergency medical care, the physician and preferred hospital to be used are:


Health Agreement
Red Bridge United Methodist Church Early Childhood Center

The following symptoms require parental contact and the sending home of a child:


  1. More than one abnormally loose stool
  2. Red or blue in the face or makes high-pitched croup or whooping sounds after coughing
  3. Difficult or rapid breathing
  4. Yellowish skin or eyes
  5. Tears, redness of eyelid lining or irritation, followed by swelling or discharge or puss (signs of pink eye)
  6. Unusual spots or rashes
  7. Sore throat or swallowing difficulty
  8. An infected skin patch: crusty, bright yellow, dry or gummy areas of the skin
  9. Unusually dark, tea-colored urine
  10. Gray or white stool
  11. Fever over 99 degrees Fahrenheit
  12. Headaches and stiff neck
  13. Vomits
  14. Contagious period of a disease
  15. Severe itching of the body or scalp or scratching of the scalp which may be symptoms of lice or scabies.
Please keep your child home if they have any of the above symptoms OR have had a fever, vomited or had diarrhea within 24 hours of a school day.

Please notify the ECC office if your child is not feeling well and will not be attending preschool that day.

Be sure you or your emergency contact can be reached on days that your child attends ECC.


Picture Release

I hereby do/do not give consent to let my child be photographed for use by the Red Bridge United Methodist Church Early Childhood Center.  The photographs may be used in the classroom, in the hallways, on our website or Facebook page, or in our spring slideshow.  No information that would identify my child will be included if his or her photograph is used on the website or Facebook page.

Acceptance of Terms

1.  I have fully disclosed any special needs or development delays my child may have.  For proper placement and care, this information is needed at the time of enrollment.  The Early Childhood Center has the right to refuse registration or dismiss a child if proper care and educational needs cannot be provided for the child.

2. I understand that classes may be cancelled if the minimum requirement is not met.  If a class must be cancelled due to low enrollment, we will contact you by August 1.

3. I understand I must pay one months's tuition each month by the 10th of the month or a $15.00 late fee will be charged.

4. I understand that I am required to give the office a 30 day written notice if I am going to withdraw my child from the program for any reason.  I understand that I am responsible for that month's tuition.

5.  I understand that I must provide a signed Medical Examination Report for my child and his/her shot record.  This must be on file in the office before the first day of school.


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