Registration Form

If your child is CURRENTLY enrolled in one of our preschools:
Complete the registration form below. Birth certificates and immunization records are NOT required for returning students; however, proof of address or registration fee IS required.

If your child is NEW to our program:
Complete the following registration form and submit the applicable supporting documents.

Important! –> Your child will NOT be fully registered until our office receives the supporting documents:

A copy of the child’s birth certificate.
A copy of the child’s UTAH immunization card.

AND . . .

For students registering for a Limited Admission school (see list):
(Check the School Search Boundary Lookup to know if this applies to you. Limited Admission schools are listed to the right.)

A copy of a Proof of Address. (A recent copy of an electricity, gas, or water bill in the parent’s name, or rental agreement or mortgage statement in the parent’s name that lists the address as a “service address” or a “property address” — no other proof of address will be accepted.)

For students registering for an Open Admission school (see list):

A $40 non-refundable registration fee and the first month’s tuition (if applicable). These fees can be paid by calling our office with a credit or debit card.
The first month’s tuition.

CHECKS ARE NO LONGER ACCEPTED!!

INSTRUCTIONS FOR PROVIDING THIS INFORMATION WILL BE LISTED AFTER YOU HAVE SUCCESSFULLY SUBMITTED THE REGISTRATION FORM.

** If you are using a mobile device to complete this form, it may not send! Please use another method or call our office to confirm receipt of application.**

If you would like your child to begin attending on August 19th (first day of preschool), you must have FULLY registered, including submitting all required documents and fees, by JULY 25!!

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NOTE: This registration form is for the 2024-2025 school year ONLY.

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Registration Form

"*" indicates required fields

Has this child been enrolled in our program or on our waiting list before?*

Yes

School Selection

Do you live within the boundaries of a Limited Admission (Title I) elementary school? (If you have a Preschool Permit to attend a Limited Admission school, choose "yes".)*

Yes

Limited Admission (Title I) School Choice

School Preference

If space is not available at your preferred school, what is your 2nd choice?

Which do you prefer?

mornings

afternoons

any

Do you have younger children at home (0-3 years old)?*

Yes

Would you like to help prepare your younger children for preschool?*

We are excited to partner with Help Me Grow Utah to connect you with this information. They provide free developmental screenings and resources to support your younger child’s development. Please mark below to give us permission to share your contact information with Help Me Grow Utah.

Yes, I want more information to support my younger child’s development

No, I do not want to share my contact information

Funding Source

Our preschool’s financial support comes from multiple sources. In order to determine your child’s funding sources, please answer the following questions.

Does your family qualify for free or reduced lunch?*

Yes – Free Lunch

Yes – Reduced Lunch

No, not free or reduced lunch

I don’t know

How many people live in your household?

Is the gross (before tax) household income less than $3,151 per month?

yes

Is the gross (before tax) household income less than $3,981 per month?

yes

Is the gross (before tax) household income less than $4,810 per month?

yes

Is the gross (before tax) household income less than $5,639 per month?

yes

Is the gross (before tax) household income less than $6,469 per month?

yes

Is the gross (before tax) household income less than $7,298 per month?

yes

Is the gross (before tax) household income less than $8,128 per month?

yes

How many of those circumstances apply to your preschooler?*

READ THE LIST BELOW AND COUNT HOW MANY OF THESE CIRCUMSTANCES APPLY TO YOUR PRESCHOOLER:

Child born to mother who was 18 years old or younger
A member of child’s household is incarcerated
Child lives in a neighborhood with high violence/crime
One or both parents have a low reading ability
Family has moved at least once in the last year
Child has ever been in foster care
Lives in a household with multiple families
Child exposed to physical abuse or domestic violence in the home at any time in their life
Child exposed to substance abuse (drugs or alcohol) in the home at any point in their life
Child exposed to stressful life events (death, chronic illness or mental health issues of a parent or sibling)
Language spoken in the home most often is NOT English
A parent of the child did not graduate from high school

Is the child currently in Foster Care?*

yes

Is your child an English Learner? (see definition below)?*

yes

The child:
– was not born in the United States, or whose native language is NOT English, or
– is a Native American or Alaska Native, or a native resident of the outlying areas and comes from an environment where a language other than English has had a significant impact on their level of English Language proficiency, or
– is migratory, whose native language is NOT English and who comes from an environment where a language other than English is dominant
AND
has difficulties in speaking reading, writing, or understanding the English language that may be sufficient to deny the child the ability to meet challenging state academic standards or successfully achieve in English-instructed classrooms, or the opportunity to participate fully in society.

Affirmation: By checking the box below, I certify that the prior information I have provided is true and accurate to the best of my knowledge.*

I am a parent of the child and I agree with the above statement.

Child's Information

Legal FIRST Name (Primer Nombre)*

Legal MIDDLE Name

Legal LAST Name (Apellido)*

Child's Gender*

Female

Male

Child's Birthdate*

Child's Age on September 1, 2024:*

2 years old

3 years old

4 years old

If your child is 5+ years old on this date, they must register for kindergarten. Please contact your local school.

If your child will NOT be turning 3 during the next month, you must wait to complete this registration. Otherwise, please select one of the following schools that offer a Young 3s program:

Child's PRIMARY Race / Ethnicity*

Asian

Black

Caucasian

Hispanic / Latino

Pacific Islander

Native American / Alaskan Native

What language does the child speak most often? (If they do not yet speak, what language is most often spoken at home?)*

What language did the child learn first? (If they do not yet speak, what language is most often spoken at home?)*

What is the language most often spoken in the home?*

What is the preferred language for written notices?*

English

Spanish

Please list any brothers and sisters living at home.

Name

Birthdate

To add additional siblings, please click the “+” button.

With whom does the child live?*

Both Mother and Father

Mother

Father

Other

Primary Contact Information (Parent or Legal Guardian)

Primary Contact's First Name*

Primary Contact's Last Name*

Primary Contact's Street Address*

Apartment #

Primary Contact's City*

Primary Contact's Zip Code*

Primary Contact's Relationship to Student*

Primary Contact's Cell Phone Number*

Primary Contact's Home Phone Number

Primary Contact's Work Phone Number

Primary Contact's Email Address – THIS IS IMPORTANT: the majority of preschool communication will be sent via email*

Enter Email Confirm Email

Secondary Contact Information (Parent or Legal Guardian)

Secondary Contact's First Name

Secondary Contact's Last Name

Secondary Contact's Street Address

Secondary Contact's City

Secondary Contact's Zip Code

Secondary Contact's Relationship to Student

Secondary Contact's Cell Phone Number

Secondary Contact's Home Phone Number

Secondary Contact's Work Phone Number

Secondary Contact's Email

Emergency Information

Please provide up to three emergency contacts other than those listed above.

Emergency Contact's Full Name (please list someone not listed above)*

Emergency Contact's Relationship to Student*

Emergency Contact's Phone Number*

Is this emergency contact also permitted to pick up the student?*

yes

Full Name – Emergency Contact 2

Relationship to Student

Phone

Is this emergency contact also permitted to pick up the student?

yes

Full Name – Emergency Contact 3

Relationship to Student

Phone

Is this emergency contact also permitted to pick up the student?

yes

Restrictions

Pick Up Restrictions – NOT allowed to pick up student

Please include the persons’ name, relationship to the student, and phone number if available.
Use a separate line for each person.
If you have a LEGAL DOCUMENT restricting someone from contact with your child, please list that person here and provide a copy of the document along with other registrations materials. If there is no legal document, do not list anyone here.

Hidden

Name

If you have a LEGAL DOCUMENT restricting someone from contact with your child, please list that person here and provide a copy of the document along with other registrations materials. If there is no legal document, do not list anyone here.

Hidden

Relationship to Child

Pick Up Restrictions – NOT allowed to pick up student – If you have a LEGAL DOCUMENT restricting someone from contact with your child, please list that person here and provide a copy of the document along with other registrations materials. If there is no legal document, do not list anyone here.

Hidden

Phone Number

Additional Information

Other Requests

(i.e., days of the week, teacher preference, placement with a sibling, etc.)

Health Information

Physician and/or Specialist Details

Name

Phone #

Does your child have any of the following?

Allergies (Foods, Medications, etc.)*

Yes

Allergy Details*

Does child have an Epi Pen / Antishistmane?*

Yes

Epi Pen / Antihistamine Details*

Asthma*

Yes

Asthma Details*

Is a "rescue" inhaler needed in the class?*

Yes

Inhaler Details*

G-tube*

Yes

G-tube Details*

Chronic condition / medical diagnosis*

Yes

Condition / Diagonisis Details*

Diabetes*

Yes

Diabetes Details*

Heart or circulatory disorder*

Yes

Heart Details*

Musculoskeletal/mobility disorder*

Yes

Musculoskeletal/Mobility Details*

Seizures*

Yes

Seizures Details (list type & daily medications)*

Visual/hearing impairment*

Yes

Visual/Hearing Details*

Tuition Agreement

Please read the listed information below and check that you agree.*

I have read and agree to the information listed below.

• A $40, non-refundable registration fee is required before your child can be placed in a class. Please call our office (385.646.4675) with a credit or debit card number to pay this fee after all required documents are received by our office.

• Tuition is calculated yearly and divided based upon a nine-month program. Your child’s monthly tuition will be:

*** $80 ***

*** $150 ***

*** $200 ***

• Tuition is due on the 20th of the month prior to the dates of attendance. A tuition statement will be mailed to your home address each month. Please notify the office immediately if your address or email address changes during the school year.
• A $10 late fee will be charged for any tuition paid after the 25th of each month.
• If the current month’s tuition, plus a $10 late fee, is not paid by the 30th of the month, your child will be withdrawn and a child from the waiting list will be registered in your child’s place.
• Tuition cannot be deducted or refunded for days missed by your child due to illness, vacation or withdrawing early. Please refer to our yearly calendar or your invoice for monthly attendance dates.
• All withdrawals must be done through the preschool office, not via communication with teachers. If not, you will be billed for each month your child remains enrolled.
• I agree to pay my child’s tuition via one of the methods listed below.

Choose one payment method*

Automatic credit or debit card. Payment is charged on the 20th. You must call our office in August to set up payment arrangements.

Pay each month by calling the office with credit or debit card number.

Pay in person each month with cash (exact change only).

Payments are due on the 20th of each month. In August, Please call our office (385.646.4675) with your credit card number and expiration date. We accept Visa, MasterCard, and Discover Card.

You must call our office by 4:00 pm on the 25th of each month in order to avoid a $10 late fee. Our office number is 385.646.4675.

You must pay in person at the Preschool office with exact change only and the bottom portion of your invoice. Payments must be made between the hours of 9:00 am and 4:00 pm.

I enter into this agreement with Preschool Services regarding payment of tuition for my child. By check the box below, I affirm that I have read and accept the conditions of this agreement.*

I agree

Participation Agreement

I agree that:*

Please read the following conditions for participation and CHECK EACH BOX to indicate your agreement.

Student’s data may be shared with an independent evaluator for Research & Evaluation purposes, subject to federal law.

Parents must attend parent-teacher conferences two times per year.

Students who enroll in this program will be tested periodically througout the school year to monitor academic progress.

The school year begins August/September and continues through May.

The preschool program is four days per week for 4 year olds, or 2 days per week for 3 year olds, and REGULAR ATTENDANCE IS EXPECTED. If your child has excessive absences or tardies, they will be dropped from the class and their space will be filled with a child from the waiting list. If student absences exceed 40% of any month, they will be withdrawn. If your child is absent, you must notify the teacher and state the reason for the absence.

Parent participation is an important part of a child’s educational success. Therefore, parents are strongly encouraged to attend parent education opportunities to enhance their child’s development of literacy and math skills at home.

All information contained in this application is true and accurate to the best of my knowledge.

How did you hear about our program?

Flyer

Internet

Returning Student

Referred by Someone

Elementary School Sign/Web Page/Newsletter

Other

After clicking the ‘Submit’ button below, please wait until you see a confirmation page. Do not refresh.