Child's Information

Child's Full Name*

Name the Child Goes By*

Date of Birth (must be four by 12/1; three by 9/1)*

Gender*

Male

Female

Other

Parent/Guardian Information

Parent/Guardian Name*

Relationship to Child*

Cell Phone*

Home Phone

Employer*

Position/Title*

Work Hours*

Work Phone*

Email Address*

Parent/Guardian's Name

Relationship to Child

Cell Phone

Home Phone

Employer

Position/Title

Work Hours

Work Phone

Email Address

Emergency Contacts

Please list any additional emergency contacts authorized to act for the parents/guardians in an emergency.

Name*

Relationship to Child*

Cell Phone

Home Phone

Name

Relationship to Child

Cell Phone

Home Phone

Pick-Up Authorization

Please list any additional contacts, other than the parents/guardians and emergency contacts, authorized to pick p your child:

Name

Cell Phone

Home Phone

Name

Cell Phone

Home Phone

Family Information

Does the family have a parenting plan with the child splitting time between parents/guardians?*

Yes

No

If yes, please describe the parenting plan:

Does the family have a custody order that restricts one parent's access to the child?*

Yes

No

If yes, briefly describe it here (a Certified Court-Ordered Custody Order must be submitted with this form):

Upload Certified Court-Ordered Custody Order

Please list all adults living in the child's household(s) and their relationship to the child (parent, grandparent, ect.):*

Please list any other children in the family:*

Media Consent

During the school year, the staff at Small Wonders may want to interview, photograph, or videotape your child for promotional materials and social media. The photographs and videos may be of groups of children or individuals. No names will be used.*

Yes, permission is granted for my child.

No, permission is not granted for my child. Please do not publish any interviews, photographs, or videos of my child.

Support Services/Special Needs

Does your child receive any of the following support services?

IEP (please provide a copy)

Early Intervention

Special Education

Occupational Therapy

Speech/Language Therapy

Physical Therapy

Other

If other, please explain:*

Child's Medical Information

Does your child have any medical conditions that require ongoing care?*

Yes

No

If yes, please explain:

Does your child have any allergies?*

Yes

No

If yes, please list all allergies and indicate severity (You will be required to submit an Allergy Action Plan):

Does your child require an EpiPen?*

Yes

No

If yes, for what?

List any medications your child is currently taking and the dosage:*

Anything else we should know?*

Name of Pediatrician*

Practice Name*

Phone Number*

Child's Personality & Development

Do you have any concerns regarding your child's development or behaviors that you want to share with us?*

Which of the following words best describe your child's personality? Check all that apply.*

Adaptable

Mature

Quick Tempered

Reserved

Shy/Quiet

Mischievous

Cautious

Sensitive

Happy

Affectionate

Friendly

Energetic

Adventurous

Strong Willed

Confident

Independent

Playful

Inquisitive

Easy-Going

Calm

What are some of your child's favorite things to play at home?*

Does your child have any special interests?*

Does your child play with children from other families?*

How does your child react when he or she does not get their own way?*

Anything else we should know?*

Parent/Guardian Declarations

I have read the Small Wonders Preschool Family Handbook and agree to follow all of the policies.
My child is up-to-date on their immunizations. I will submit an up-to-date certificate of immunization.
I hereby authorize emergency medical care for my child. In the event of an accident or illness, I grant permission to
the Small Wonders Preschool staff or representatives to administer necessary first aid and/or call an ambulance to
take my child to the nearest medical facility for additional care.
I have reviewed the tuition payment schedule and agree to the outlined tuition policies.
I agree to promptly notify Small Wonders Preschool of any changes to my child’s demographics, medical/
behavioral needs, or any important information needed to properly care for my child.
I understand that the application fee is non-refundable and non-transferable. The application fee covers
administrative costs and will not be applied towards tuition. I acknowledge that I will need to pay the tuition
deposit to reserve my child’s placement should my application be accepted. The tuition deposit is non-refundable.

I agree with the terms & conditions above

Preschool Agreement

Our promise to you:

Provide a loving, nurturing, and supportive environment for children
Offer opportunities for children to grow cognitively, emotionally, socially, and physically
Communicate pertinent information with you about your child and our program

Your promise to us:

Follow all established Small Wonders Preschool policies and procedures
Follow payment procedures in a timely and accurate manner
Read and discuss rules and updates with your child
Inform us of any changes in registration information, attendance, or payment options

Parent/ Guardian Signature

I have read the above terms and understand that by signing, I agree to follow all outlined terms and conditions.

A $100 non-refundable application fee must be submitted with this form for Small Wonders Preschool to process the application.

Name of Parent/Guardian (please print):*

Parent/Guardian Signature*

Reset

Registration & Tuition Policy & Procedure

Procedure:

Complete the Registration Application electronically or download and print to mail.
Pay the non-refundable/non-transferable $100 application fee. Application fees may be paid electronically utilizing the Pay Online feature found on our website. You may also mail a check or hand-deliver it to the Small Wonders locked drop box located at 1900 Westfall Road, Rochester, NY 14618.
Small Wonders Preschool will contact you to confirm your placement. Should your application be accepted, you will receive a contract to sign and make a $200 tuition deposit to secure your child’s spot at SWP. The deposit will be applied to your annual tuition.

Schedule:

November 15th - Application Period Opens for Currently Enrolled Families
December 1st - Application Period Opens For General Public
February 1st - Registration confirmations and contracts will be sent to families
April 1st - Signed contracts and tuition deposits are due to reserve placement
August 1st - Medical Forms and Immunization Records are due

5-day 4-year-old program 9:00 am-12:00 pm

*Total Annual Tuition
$4,250

*Tuition Deposit
$200

*Net Annual Amount
$4,050

*Net Monthly Amount
$450

3-day 3-year-old program 9:00 am-12:00 pm

*Annual Tuition
$2,360

*Tuition Deposit
$200

*Net Annual Amount
$2,160

*Net Monthly Amount
$240

*The registration application fee of $100 is not applied to the annual tuition rates. The registration application fee covers administrative costs. The tuition deposit of $200 will be applied to yearly tuition and will reserve your child’s spot at Small Wonders Preschool.

Tuition Payment Options:

A. Tuition may be paid in full by September 1st at the rate of $4,050 (4s)/$2,160(3s)
B. Tuition may be paid monthly at the rate of $450(4s)/$240(3s)

Monthly Payments are due on the first day of the month, September-May, for a total of 9 payments.

*Tuition not received by the 5th day of the month will be subject to a 10% late fee.
*Unpaid tuition and interest by the 10th day of the month will result in temporary suspension until payment is received.
*There is a $50 handling charge for each check returned by the bank for insufficient funds or any other reason.

Registration Form

Child's Information

Parent/Guardian Information

Emergency Contacts

Pick-Up Authorization

Family Information

Media Consent

Support Services/Special Needs

Child's Medical Information

Child's Personality & Development

Parent/Guardian Declarations

Preschool Agreement

Parent/ Guardian Signature

Registration & Tuition Policy & Procedure

Ready to Join Our Small Wonders Family?