2023-2024 Online Registration form&lt;div&gt;&lt;div&gt;&lt;div&gt;&lt;div&gt;St. Joseph Preschool&lt;/div&gt;&lt;/div&gt;&lt;/div&gt;&lt;/div&gt;

# of Students being Registered REQUIRED Please fill out this field.
Child 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Name you would like your child to learn to copy & trace REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Gender REQUIRED Male Female Please fill out this field.
- Class REQUIRED Little Dippers (Mon. & Wed. 9am-10:30am) MUST BE 2 yrs. by Sept. 1- $135 Big Dippers (Tues. Wed. & Thurs. 9:15am-11:45am) MUST BE 3 yrs. by Sept. 1- $160 Shooting Stars (Mon.-Thurs. 9am-11:30am) MUST BE 4 yrs. by Sept. 1- $185 Please fill out this field.
- Allergies (food, medication, environment...) If not applicable put NONE or N/A REQUIRED Please fill out this field. Please enter valid data.
- Medical Conditions/Educational Needs (Examples include but are not limited to chronic illnesses, glasses, asthma, etc.) REQUIRED Please fill out this field. Please enter valid data.
- Has your child received early intervention services(AIU, DART, other) and if so, do they have a current IFSP or IEP in place? Please enter valid data.
Child 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Name you would like your child to learn to copy & trace REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Gender REQUIRED Male Female Please fill out this field.
- Class REQUIRED Little Dippers (Mon. & Wed. 9am-10:30am) MUST BE 2 yrs. by Sept. 1- $135 Big Dippers (Tues. Wed. & Thurs. 9:15am-11:45am) MUST BE 3 yrs. by Sept. 1- $160 Shooting Stars (Mon.-Thurs. 9am-11:30am) MUST BE 4 yrs. by Sept. 1- $185 Please fill out this field.
- Allergies (food, medication, environment...) If not applicable put NONE or N/A REQUIRED Please fill out this field. Please enter valid data.
- Medical Conditions/Educational Needs (Examples include but are not limited to chronic illnesses, glasses, asthma, etc.) REQUIRED Please fill out this field. Please enter valid data.
- Has your child received early intervention services(AIU, DART, other) and if so, do they have a current IFSP or IEP in place? Please enter valid data.
Child 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Name you would like your child to learn to copy & trace REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Gender REQUIRED Male Female Please fill out this field.
- Class REQUIRED Little Dippers (Mon. & Wed. 9am-10:30am) MUST BE 2 yrs. by Sept. 1- $135 Big Dippers (Tues. Wed. & Thurs. 9:15am-11:45am) MUST BE 3 yrs. by Sept. 1- $160 Shooting Stars (Mon.-Thurs. 9am-11:30am) MUST BE 4 yrs. by Sept. 1- $185 Please fill out this field.
- Allergies (food, medication, environment...) If not applicable put NONE or N/A REQUIRED Please fill out this field. Please enter valid data.
- Medical Conditions/Educational Needs (Examples include but are not limited to chronic illnesses, glasses, asthma, etc.) REQUIRED Please fill out this field. Please enter valid data.
- Has your child received early intervention services(AIU, DART, other) and if so, do they have a current IFSP or IEP in place? Please enter valid data.
Child 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Middle Name Please enter valid data.
- Name you would like your child to learn to copy & trace REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Gender REQUIRED Male Female Please fill out this field.
- Class REQUIRED Little Dippers (Mon. & Wed. 9am-10:30am) MUST BE 2 yrs. by Sept. 1- $135 Big Dippers (Tues. Wed. & Thurs. 9:15am-11:45am) MUST BE 3 yrs. by Sept. 1- $160 Shooting Stars (Mon.-Thurs. 9am-11:30am) MUST BE 4 yrs. by Sept. 1- $185 Please fill out this field.
- Allergies (food, medication, environment...) If not applicable put NONE or N/A REQUIRED Please fill out this field. Please enter valid data.
- Medical Conditions/Educational Needs (Examples include but are not limited to chronic illnesses, glasses, asthma, etc.) REQUIRED Please fill out this field. Please enter valid data.
- Has your child received early intervention services(AIU, DART, other) and if so, do they have a current IFSP or IEP in place? Please enter valid data.

Parent/Guardian 1

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Street Address of Parent/Guardian 1 REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Occupation & Employer Parent 1 REQUIRED Please fill out this field. Please enter valid data.

Parent 1 Cell Phone REQUIRED Please fill out this field. Please enter a phone number.

Parent 1 Work Phone Please enter valid data.

Parent 1 Home Phone Please enter a phone number.

Parent 1 E-mail Address REQUIRED Please fill out this field. Please enter an email address.

Parent/Guardian 2

First Name Please enter valid data.

Last Name Please enter valid data.

Occupation & Employer Parent 2 Please enter valid data.

Parent 2 Work Phone Please enter valid data.

Parent 2 Cell Phone Please enter a phone number.

Parent 2 E-mail Address Please enter an email address.

Address of Parent/Guardian 2 (if different from parent 1) Please enter valid data.

City Please enter valid data.

State

Zip Please enter a zip code.

Other Authorized Adults

For your child's safety, please list below the adults authorized to provide transportation for your child or to contact in an emergency other than you (the parents/legal guardians): REQUIRED Please fill out this field.
Authorized Adult 1
- Fist Name REQUIRED Please fill out this field. Please enter valid data.
- Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
Authorized Adult 2
- Fist Name REQUIRED Please fill out this field. Please enter valid data.
- Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
Authorized Adult 3
- Fist Name REQUIRED Please fill out this field. Please enter valid data.
- Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
Authorized Adult 4
- Fist Name REQUIRED Please fill out this field. Please enter valid data.
- Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
Authorized Adult 5
- Fist Name REQUIRED Please fill out this field. Please enter valid data.
- Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
Authorized Adult 6
- Fist Name REQUIRED Please fill out this field. Please enter valid data.
- Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.

Emergency and Medical Authorizations

In the event of an injury, I give my persmission for necessary medical treatment to be given to my child. I agree that in case of injury to my child, I will appply my own hospitalization and/or accident insurance toward the payment of expenses incurred and will not look to St. Joseph Preschool, Christ the King Parish, the Roman Catholic Diocecese of Pittsburgh, or their representatives for the payment of any medical costs or injusry related costs.
I Agree Please select this field.
I give my permission to contact emergency personnel (911) in the event of an emergency inovlving my child. If the situation is not an emerency, it is understood that St. Joseph Preschool will first contact the parents/guardians or other authorized adults listed above in this form.
I Agree Please select this field.
Physician Name REQUIRED Please fill out this field. Please enter valid data.
Physician Phone REQUIRED Please fill out this field. Please enter valid data.
Physician Address REQUIRED Please fill out this field. Please enter valid data.
Dentist Name REQUIRED Please fill out this field. Please enter valid data.
Dentist Phone REQUIRED Please fill out this field. Please enter valid data.
Dentist Address REQUIRED Please fill out this field. Please enter valid data.

Confirmation and Agreements

By checking the box below you agree that you are the parent/guardian/legal representative of the above named child(ren).

You hereby agree that you are submitting a complete and accurate registration form for you child(ren) and agree to submit the non-refundable $50 PER CHILD registration fee. Cash or Check must be received to complete registration. Please make checks payable to Christ the King Parish. Payments can be dropped of at St. Joseph Preschool or mailed to 342 Dorseyville Road, Pittsburgh, PA, 15215. Tuition is due by the 1st of each month and can be paid online or by cash/check.
I Agree Please select this field.
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.

Saint Edward Church 450 Walnut Street Blawnox, PA 15238 412-828-4066	Saint Francis Church 2599 Freeport Road Harmar, PA 15238 412-828-4066	Saint Joseph Church Administrative Center 342 Dorseyville Road Pittsburgh, PA 15215 412-963-8885
Madonna of Jerusalem Church 201 9th Street Sharpsburg, PA 15215 412-784-8700	Saint Mary Church 210 Garnier Street Sharpsburg, PA 15215 412-784-8700	Saint Scholastica Church 309 Brilliant Avenue Aspinwall, PA 15215 412-781-0186
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2023-2024 Online Registration formSt. Joseph Preschool

2023-2024 Online Registration form
St. Joseph Preschool