Registration – Trillium Christian Nature Preschool

Student Information

Enrollment Date *

Please use this format: 00/00/0000

Child's Full Name *

Nickname

Gender *

Birth Date *

Home Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Primary Parent/Guardian Information

Email is our main source of communication.

Full Name *Primary Parent or Guardian

Email Address *

Home Phone

Work Phone

Cell Phone

Home Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Occupation & Employer *

Work Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Secondary Parent/Guardian Information

Only one parent/guardian is necessary to add as primary contact. Feel free to fill out the following information if you desire to have two parents/guardians listed.

Full NamePrimary Parent or Guardian

Home Phone

Work Phone

Cell Phone

Home Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Occupation & Employer

Work Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Emergency Contact

You (parent/guardian) are required to list at least one person with whom you would feel comfortable leaving your child, and who could assume responsibility for your child if you could not be reached immediately in an emergency, or if for some reason you could not pick up your child and were unable to communicate with the program. Examples: if your child were sick and you were not accessible, or if you experienced sudden illness between work and picking up your child.

Full Name *

Daytime Phone *May be same as cell phone if this is their primary contact.

Cell Phone

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Relationship to Student *

Full NameOptional Secondary Emergency Contact

Daytime PhoneMay be same as cell phone if this is their primary contact.

Cell Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Relationship to Student

Authorization Forms

If you have not already downloaded your authorization forms, you may do so by clicking the Medical Info & Authorization Forms link below Please print, sign, and upload them here, or you may submit the signed hard copies in person.

Medical Info & Authorization Forms (2 page PDF)

Medical Info Authorization Forms

No file chosen

Additional Info About Your Child

How did you hear about Trillium Christian Nature Preschool? *

What kinds of experiences in nature has your child had and what has been his/her response? *

Has your child attended any playgroups, daycares, or preschools? If so, how long and what was their experience? *

Does your child have any special strengths or special needs that would be helpful for me to know about? *

In what areas do you feel your child might need assistance? *

Please list any evaluations your child has had, important medical history and/or services your child is currently receiving or has received previously? *

How would you describe your child? Please address the following areas: social, emotional, physical, cognitive, any fears he or she may have, special interests, sensitivities, and anything else that will help me know your child better. *

How did you hear about Trillium? *Word of MouthSocial MediaOnline SearchChoose One

Licensing Information

Note to Parents/Guardians

The licensing authority for this program is the Bureau of Licensing and Certification, Childcare Licensing Unit. Childcare programs are required to post a copy of the statement of findings and corrective action plan for the most recent visit in a location that is accessible to parents and must maintain copies of the statement of findings and corrective action plan for the preceding visit and make them available for parents to review upon request. Statements of findings and corrective action plans are also available online or by calling the unit at 603-271-9025 or 1-800-852- 3345, extension 9025.

During visits to programs licensing staff speak with children regarding the care they receive at the program if in the judgment of the licensing staff the children's response would be valuable in determining compliance with licensing rules. Licensing staff are experienced in working with children and trained to speak with children in a manner that is respectful and non-leading. Children will remain with their class or group during these conversations with licensing staff, and at no time will a child be forced to speak with a licensing coordinator. If licensing staff believes your child may have specific information regarding an alleged event at the child care program, and determines that it is best to interview your child separately and not with their class or group, please indicate your preference among the following options:

Interview Authorizations *I DO give permission for child care licensing staff to interview my child at the child care program separate from their class or group.I wish to be notified prior to child care licensing staff interviewing my child at the child care program separate from their class or group.I DO NOT give permission for child care licensing staff to interview my child at the child care program separate from their class or group.

Registration Payment

Use the button below to pay the one-time, $50 registration fee.