Rocking Horse Preschool Online Submission Form

Student Name*

First

Last

Name child goes by

Date of Birth*

day

month

year

Age of child as of Sept 1, 2018*

Select One*

Male

Female

Address*

Street Address City State / Province / Region Postal / Zip Code

Email*

School District*

Elementary School your child will attend*

Mother's Name

First

Last

Mother's Occupation

Mother's Work Phone

Mother's Cell Phone

Father's Name

First

Last

Father's Occupation

Father's Work Phone

Father's Cell Phone

Emergency Contact*

First

Last

Emergency Phone *

If class is full you may be put on a wait list.
Your child must be fully potty trained in order to attend class.

Select Class Choice*

3 Year old P.M. - Tues/Thurs 12:30-3:00

4 Year old A.M. - Mon/Wed/Fri 9:00-11:30

4 Year old P.M. - Mon/Wed/Fri 12:30-3:00

Please list any allergies

I allow my child to be photographed for the pre-school DVD, Rocking Horse website, and pre-school projects*

Yes

I agree to absolve the church and the teachers/helpers of all financial responsibility in the case of injury or illness of my child.

Parent Signature*

Date*

Please make $50 Nonrefundable deposit to:

501 Fairfield Drive

Greensburg, PA 15601

How did you hear of our preschool?

Website Referred

Referred by Friend (Name)

Other Referral

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Rocking Horse Preschool

Rocking Horse Preschool Online Submission Form

Class Times

Socialize

Upcoming Events