Parent or Guardian's email

Parent or Guardian 2's email

Parent/Guardian 1's Address

Parent/Guardian 2's Address (if different from above)

Child's Date of Birth

If race is not listed above, please specify here:

Does your child have any experience in a group setting?

For parent volunteers only: please list your preferred work day

For parent volunteers only: do you have any special talents or interests?

What do you hope your child learns at SPNS?

Emergency Consent Form

The following information is used in the event of an emergency. Please re-enter your child's name and date of birth here.

Child's Primary Care Physician

Medical Insurance Policy Number

Allergies to drugs/food or any other chronic medical conditions

Special Medications/Blood Type (if known)

If parents/guardian can't be reached, who should we contact?

By entering my name below, I authorize SPNS to consent to any necessary medical treatment for my child in the event I am unavailable. I also authorize any hospital or medical facility that treats my child to release them into the care of the authorized adult(s) after treatment. This authorization remains in effect until the end of the current school year unless revoked in writing.

Please sign below:

Requirements for Parent Participation Membership:

Parent Participation Requirements As a participating member of SPNS, I understand and agree to the following responsibilities: 1. Submit a completed registration form and pay the annual registration fee. 2. Provide proof of a negative TB test for the adult working in the classroom, prior to participation. (This can be arranged through your doctor or Tuolumne County Public Health.) 3. Pay tuition and fees by the due date each month. 4. Attend monthly parent meetings. 5. If I am unable to work on my scheduled day, I will arrange for a substitute parent and notify the Teacher/Director in advance. 6. I understand that SPNS relies on approximately $13,000 in annual fundraising. With around 25 participating families, this averages to about $500 in fundraising contribution per family each year. Families may contribute through a combination of event planning, volunteering, in-kind donations, encouraging attendance, or direct financial support. 7. I will join and actively participate in one of the following teams: Maintenance, Community Building, Fundraising, Housekeeping, or Gardening. 8.If my child wears diapers, I understand that the accompanying adult must have a negative TB test on file with the school. Please sign below:

Background Check Policy (Megan's Law & NSOPW Compliance)

At SPNS, the safety of our children is our highest priority. In accordance with our policies and California state law, all adults (age 16 and older) who will be working, volunteering, or regularly present at the school must be screened through Megan’s Law and the National Sex Offender Public Website (NSOPW). By entering names below, I authorize SPNS to perform a background check using the following publicly accessible databases: Megan's Law – https://www.meganslaw.ca.gov National Sex Offender Public Website (NSOPW) – https://www.nsopw.gov This check helps us ensure the safety of all children in our care. All information will be kept strictly confidential. Please list the full legal names of all adults (age 16+) who will be present on campus or involved in school activities (including parents, caregivers, or family members):

Waiver of Responsibility

By signing below, I acknowledge and agree that Summerville Parent Nursery School, its Director, Board, staff, and participating parents are not responsible for any accidents or injuries that may occur to my child(ren) while attending school. I understand and accept this waiver as a condition of participation

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Registration fees for the 2025-2026 School Year

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Program

Summerville Parent Nursery School