Parent or Guardian 1

First Name

Last Name

Parent or Guardian 2

First Name

Last Name

Parent or Guardian's email

Parent or Guardian 2's email

Phone #1

(###)

###

####

Phone #2

(###)

###

####

Parent/Guardian 1's Address

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

Child's Name

First Name

Last Name

Child's Date of Birth

Is your child of Hispanic, Latinx, or Spanish heritage?

Yes

What is your child's race?

White

Asian

Black/African American

Middle Eastern

Native American or Alaska Native

Native Hawaiian or Pacific Islander

Unknown

Race not listed

If race is not listed above, please specify here:

What sessions are you interested in attending?

Note: Your child can start school at any time, regardless of the start of the session.

Session 1 (August 26-October 31 2024)

Session 2 (November 4 2024-January 30 2025)

Session 3 (February 3-March 27 2025)

Session 4 (April 7-June 5 2025)

Does your child have any experience in a group setting?

Will you be participating as a parent volunteer?

Yes, I will volunteer once per week

No, drop off only

For parent volunteers only: please list your preferred work day

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

For parent volunteers only: please indicate which family team you'd like to join

Maintenance

Community Building

Gardening

Fundraising

Housekeeping

What do you hope your child learns at SPNS?

Please check if you do NOT want the following information listed in the school directory (available only to members)

Phone number

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?

In the event of an emergency, the school is authorized to proceed as indicated

Please check all that apply

Contact family physician

Take child to Adventist Health Emergency room

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

Photo Release and Permission

I consent to have my child photographed while participating in activities at and away from Summerville Parent Nursery School for the use of this school.

I do NOT consent to have my child photographed while participating in activities at and away from Summerville Parent Nursery School for the use of this school.

Payment Preferences

Tuition is requested on a per-session basis and is typically paid online via QuickBooks using ACH/bank transfer (1% fee). To support our volunteer treasurer and keep administrative work manageable, we’ve streamlined our billing process and available payment methods. We understand that some families may need alternative arrangements. If you require a different payment schedule or method, please indicate your preference below:

ACH - monthly

Check - per session

Different payment method

How did you hear about us?

Do you have any questions or comments?

(optional)

Register today.

Info

Program

Summerville Parent Nursery School