Family Information First Parent/Guardian Name*
First Parent's Daytime Phone # (Primary)*
First Parent's Email Address (Primary)* Email is our primary means of communication. Please provide a reliable email address.
Second Parent/Guardian Name
Second Parent's Daytime Phone #
Second Parent's Email Address Email is our primary means of communication. Please provide a reliable email address.
Home Address* Include Apartment/Unit # if applicable.
Language(s) Spoken at Home:*
Registered Member of:* You must be registered at SJV for at least 6 months before being eligible for parishioner tuition rate.
None/Other Other Catholic Parish St. John Vianney Parish
Date of Registration* An approximate date should be fine as long as the year and month are correct.
Enrollment Information YCP will be in session on Tuesdays and Thursdays from 9:00 am until 2:00 pm during the school year. Ages are 1 through 4 years of age on or before September 1, 2021
Tuition and Fees Registration/Supply Fee is $250.00 for the first child and $200.00 for each sibling. This fee is non-refundable and must be received for the registration to be complete. Monthly tuition is $260.00 (Parishioners) or $320.00 (Non Parishioners). Please make all checks payable to: St. John Vianney YCP (Young Children’s Program).
Online Payment Option Online payments for registration fee and/or tuition are offered via WeShare. There will be a fee of $12 per child, per transaction when using this method.
Parent/Guardian Signature* By typing my name, I certify that I have read the above information. I understand that once my registration is accepted, the registration and registration/supply fee is non-refundable. I also understand that the medical forms must be in before my child will be admitted to class.
And I hereby verify that I am this child/these children's legal guardian.
First Child Information If registering more than one, please begin with the oldest child.
Child's First Name*
Child's Last Name*
Child's Nickname (Optional)
Date of Birth* Gender* Language(s) spoken or understood by child:* List all languages separated by commas, beginning with the language child speaks/understands most of the time.
Is child 2 years old on or before September 1, 2021?* List of English words required for children 2 and older:* YCP is an English speaking program, so in order to better serve the needs of all children, we require those ages 2 and older to understand and speak the following list of English words: Come, Stop, Wait, Stay here, Sit, Bathroom, Yes, No, I am hurt, I am sad, Nap time, Lay down, Will you help me. By typing my name/initials, I confirm that I understand the importance of the above request and that if this safety element is not met, my child will be asked to leave the program.
Is this your child's first time in a school setting or away from you?* Name of previous preschool child attended:* Name of child's previous YCP Teacher:*
Dates attended:*
Are child's mother and father separated or divorced?* Please select "Yes" if your child IS NOT living with both parents.
Name of child's custody parent/legal guardian:*
Photography and/or Video Release As parent/guardian, I understand that promotional pictures and/or video (individual and group) will be taken during the year. I give permission for my son’s/daughter’s image/picture to be used for promotional materials (newsletter, web page, calendars, power point, etc.) in highlighting the program's activities.
Parent/Guardian Consent* By choosing "I Agree", I hereby consent and agree to the Photography and/or Video Release.
I Agree I Do Not Agree
Medical Conditions Information Please complete the following questions to help us better serve your child. (YCP Staff will take reasonable care to see that the following information will be held in confidence.)
My son/daughter has/has had the following:* Select all that apply.
None/Other Allergies (Please list below) Vision Corrections Hearing Corrections Speech Problems Learning Problems
Allergic reactions:* Indicate any known allergies to foods, dyes, latex, medications, etc. Or if they use an Epi Pen.
Immunizations current and up to date:* Upload Immunization Records Immunization records are required in order to complete your child's registration and need to be uploaded and submitted with this form or turned in to a YCP employee in the Library Den during YCP hours.
Other special conditions of my child:* Is there any condition that we should be aware of in order to better serve your child?
Child's Physician*
Physician's Phone #*
Consent & Liability Waiver If my child becomes ill or is injured, I authorize St. John Vianney Catholic Church and its agents to obtain emergency medical treatment and I hereby release said church and its agents from liability for action taken pursuant to this release. Having been informed of the organization of the Young Children’s Program of St. John Vianney Catholic Church to provide child care and teaching for boys and girls, we, the parents of the above named child, do hereby give our approval to his/her participation in the Young Children’s Program during the current year. Knowing that St. John Vianney Catholic Church has general liability coverage, but that no accident policy is being carried for the Young Children’s Program, we do assume all risks and hazards incidental to the conduct of its activities; and we do further hereby release, absolve, and indemnify and hold harmless the St. John Vianney Catholic Church, the organizers, sponsors and workers of the Young Children’s Program, and/or all of them. In case of injury of my son/daughter, I hereby waive all claims against St. John Vianney Catholic Church, the organizers and sponsors of the Young Children’s Program or any of the workers or supervisors appointed by them.
Parent/Guardian Signature* By typing my name, I hereby consent and agree to the Consent and Liability Waiver.
Add a second child? Second Child Information Child's First Name*
Child's Last Name*
Child's Nickname (Optional)
Date of Birth* Gender* Language(s) spoken or understood by child:* List all languages separated by commas, beginning with the language child speaks/understands most of the time.
Is child 2 years old on or before September 1, 2021?* List of English words required for children 2 and older:* YCP is an English speaking program, so in order to better serve the needs of all children, we require those ages 2 and older to understand and speak the following list of English words: Come, Stop, Wait, Stay here, Sit, Bathroom, Yes, No, I am hurt, I am sad, Nap time, Lay down, Will you help me. By typing my name/initials, I confirm that I understand the importance of the above request and that if this safety element is not met, my child will be asked to leave the program.
Is this your child's first time in a school setting or away from you?* Name of previous preschool child attended:* Name of child's previous YCP Teacher:*
Dates attended:*
Are child's mother and father separated or divorced?* Please select "Yes" if your child IS NOT living with both parents.
Name of child's custody parent/legal guardian:*
Photography and/or Video Release As parent/guardian, I understand that promotional pictures and/or video (individual and group) will be taken during the year. I give permission for my son’s/daughter’s image/picture to be used for promotional materials (newsletter, web page, calendars, power point, etc.) in highlighting the program's activities.
Parent/Guardian Consent* By choosing "I Agree", I hereby consent and agree to the Photography and/or Video Release.
I Agree I Do Not Agree
Medical Conditions Information Please complete the following questions to help us better serve your child. (YCP Staff will take reasonable care to see that the following information will be held in confidence.)
My son/daughter has/has had the following:* Select all that apply.
None/Other Allergies (Please list below) Vision Corrections Hearing Corrections Speech Problems Learning Problems
Allergic reactions:* Indicate any known allergies to foods, dyes, latex, medications, etc. Or if they use an Epi Pen.
Immunizations current and up to date:* Upload Immunization Records Immunization records are required in order to complete your child's registration and need to be uploaded and submitted with this form or turned in to a YCP employee in the Library Den during YCP hours.
Other special conditions of my child:* Is there any condition that we should be aware of in order to better serve your child?
Child's Physician*
Physician's Phone #*
Consent & Liability Waiver If my child becomes ill or is injured, I authorize St. John Vianney Catholic Church and its agents to obtain emergency medical treatment and I hereby release said church and its agents from liability for action taken pursuant to this release. Having been informed of the organization of the Young Children’s Program of St. John Vianney Catholic Church to provide child care and teaching for boys and girls, we, the parents of the above named child, do hereby give our approval to his/her participation in the Young Children’s Program during the current year. Knowing that St. John Vianney Catholic Church has general liability coverage, but that no accident policy is being carried for the Young Children’s Program, we do assume all risks and hazards incidental to the conduct of its activities; and we do further hereby release, absolve, and indemnify and hold harmless the St. John Vianney Catholic Church, the organizers, sponsors and workers of the Young Children’s Program, and/or all of them. In case of injury of my son/daughter, I hereby waive all claims against St. John Vianney Catholic Church, the organizers and sponsors of the Young Children’s Program or any of the workers or supervisors appointed by them.
Parent/Guardian Signature* By typing my name, I hereby consent and agree to the Consent and Liability Waiver.
Add a third child? Third Child Information Child's First Name*
Child's Last Name*
Child's Nickname (Optional)
Date of Birth* Gender* Language(s) spoken or understood by child:* List all languages separated by commas, beginning with the language child speaks/understands most of the time.
Is child 2 years old on or before September 1, 2021?* List of English words required for children 2 and older:* YCP is an English speaking program, so in order to better serve the needs of all children, we require those ages 2 and older to understand and speak the following list of English words: Come, Stop, Wait, Stay here, Sit, Bathroom, Yes, No, I am hurt, I am sad, Nap time, Lay down, Will you help me. By typing my name/initials, I confirm that I understand the importance of the above request and that if this safety element is not met, my child will be asked to leave the program.
Is this your child's first time in a school setting or away from you?* Name of previous preschool child attended:* Name of child's previous YCP Teacher:*
Dates attended:*
Are child's mother and father separated or divorced?* Please select "Yes" if your child IS NOT living with both parents.
Name of child's custody parent/legal guardian:*
Photography and/or Video Release As parent/guardian, I understand that promotional pictures and/or video (individual and group) will be taken during the year. I give permission for my son’s/daughter’s image/picture to be used for promotional materials (newsletter, web page, calendars, power point, etc.) in highlighting the program's activities.
Parent/Guardian Consent* By choosing "I Agree", I hereby consent and agree to the Photography and/or Video Release.
I Agree I Do Not Agree
Medical Conditions Information Please complete the following questions to help us better serve your child. (YCP Staff will take reasonable care to see that the following information will be held in confidence.)
My son/daughter has/has had the following:* Select all that apply.
None/Other Allergies (Please list below) Vision Corrections Hearing Corrections Speech Problems Learning Problems
Allergic reactions:* Indicate any known allergies to foods, dyes, latex, medications, etc. Or if they use an Epi Pen.
Immunizations current and up to date:* Upload Immunization Records Immunization records are required in order to complete your child's registration and need to be uploaded and submitted with this form or turned in to a YCP employee in the Library Den during YCP hours.
Other special conditions of my child:* Is there any condition that we should be aware of in order to better serve your child?
Child's Physician*
Physician's Phone #*
Consent & Liability Waiver If my child becomes ill or is injured, I authorize St. John Vianney Catholic Church and its agents to obtain emergency medical treatment and I hereby release said church and its agents from liability for action taken pursuant to this release. Having been informed of the organization of the Young Children’s Program of St. John Vianney Catholic Church to provide child care and teaching for boys and girls, we, the parents of the above named child, do hereby give our approval to his/her participation in the Young Children’s Program during the current year. Knowing that St. John Vianney Catholic Church has general liability coverage, but that no accident policy is being carried for the Young Children’s Program, we do assume all risks and hazards incidental to the conduct of its activities; and we do further hereby release, absolve, and indemnify and hold harmless the St. John Vianney Catholic Church, the organizers, sponsors and workers of the Young Children’s Program, and/or all of them. In case of injury of my son/daughter, I hereby waive all claims against St. John Vianney Catholic Church, the organizers and sponsors of the Young Children’s Program or any of the workers or supervisors appointed by them.
Parent/Guardian Signature* By typing my name, I hereby consent and agree to the Consent and Liability Waiver.
