3–5 Year Old Classes

Dear Mr./Mrs./Ms. _________________________________              Date ___________________

We would like to welcome you and your child to the LR Preschool.  In order to have your child registered properly, we will require the following:

   Registration Fee {{body}}nbsp; |   Consent for Bathroom Escort / Change of Clothing
   June  Tuition  {{body}}nbsp; |    Birth Certificate ( Xerox Copy )
   Registration Form |    Consent for Excursions
   Parent Contract / Health History |    General Meeting Contract
   Immunization Record  |    Student Release Form
   Picture Consent Form |    Annual Insurance Fee

Registration forms can be found on our website at

Kindly mail your completed forms to:

3 Year Old Registrations | 4-5 Year Old Registrations
LR Preschool | LR Preschool
Attn: 3 Year Old Registration | Attn: 4-5 Year Old Registration
200 W. Main StreetSayville, NY 11782 | 200 W. Main StreetSayville, NY 11782
(631) 589-3210 Ext. 3 | (631)  589-3210 Ext. 4

3–5 Year Old Classes

Child’s Name:________________________________   M (   )   F  (  )  Date of Birth:___________________

Parent’s Name(s):   Mother_________________________ Father:__________________________________


Town:______________________ Zip Code:  ____________       Home Phone No.: ___________________

Email address*: ____________________________________  Cell Phone No.: _____________________

* LRPS does not sell, rent, or otherwise release your email address to any third party, nor do we use it for
any purpose other than to email you the school notices and reminders.

Please place an X mark for your first (1st) and second (2nd) choice of session and days:

Time / Schedule
   A.M. session: 9:30 a.m. – 12:00 p.m. |    P.M. session: 12:30 – 3:00 p.m.
     3 Year Old Classes |      4-5 Year Old Classes
   A.M.  – Tue, Thu, Fri  ( 3A )  |    A.M. – Mon, Tue, Wed, Thu, Fri ( 4A )
   A.M. – Mon, Wed, Fri ( 3B )   P.M. – Mon, Wed, Fri ( 3C ) |          P.M. – Mon, Tues, Wed, Thu, Fri ( 4B )
Please choose the time that is most convenient for you.  (Teachers’ schedules will not be decided until late summer.)

How did you hear about LR Preschool? ______________________________________

Kindly mail your completed Registration Form to:

3-Year-Old Registrations | 4-5 Year Old Registrations
LR Preschool | LR Preschool
Attn: 3 Year Old Registration | Attn: 4-5 Year Old Registration
200 W. Main StreetSayville, NY 11782 | 200 W. Main StreetSayville, NY 11782
(631)  589-3210 Ext. 3 | (631)  589-3210 Ext. 4

3-5 Year Old Classes


Name of Child: __________________________________________________________________________
                       (Last)                                           (First)                                     (Middle Initial)
Date of Birth: ________________________________ Phone Number:   ____________________________

Mother’s Name: _____________________________ Father’s Name:  _____________________________

Address: ________________________________________________________________________________


I agree to prepay a tuition fee in the amount of $________, plus a registration fee of $65.00 payable at the time of enrollment.  The tuition fee shall represent payment of tuition for the last month of school in June.  Your regular monthly tuition in the amount of $________ shall be due September 1, and due the first of each month thereafter for the months of October - May.  Tuition received after the due date is automatically subject to a $10.00 fine.  When tuition is not received within 10 days of due date, your child can be subject to dismissal from the school.

I agree that my child is entered for the entire school year and that I am obligated to pay tuition until written notice of withdrawal is presented to the Executive Board, 30 days prior to withdrawal.  I understand that no refund of the registration will be made under any circumstance.  I further understand that this is a cooperative pre-school and I agree to follow the regulations governing the school.  *Tuition refunds will not be made after March 1.  If for any reason you withdraw your child from school and a replacement cannot be found, June tuition will not be refunded.    ** A copy of the Bylaws is available at the preschool.  The Bylaws are also available on our web site at **

There will be a one-time annual insurance fee of $100.00 due at the time of registration. This fee is non-refundable.

I agree to one mandatory school designated fundraiser wherein my child will be required to sell raffle tickets.

In case of serious injury, if I cannot be contacted, the School has my permission to contact the local emergency services unit. 

_________________________________________________                 ______________________         
        Signature of Parent / Legal Guardian                                              Date

Dear Parents/Guardians:

LR Preschool requires a one-time annual insurance fee of $100.00 per child enrolled in the programs offered. Please provide this payment with September tuition payments. Thank you.

Best Regards,

The Executive Committee


Total # of Children Enrolled:  __________________    X    $100. 00 each      =    Total Amount Due:  ______________

Child’s Name    Class






Child’s Name: ____________________________________ M (  ) F (  )  Date of Birth: __________________

Parent / Legal Guardian: _______________________________________ Phone No.:  ___________________

OTHER THAN YOURSELF, Person(s) we can contact in case of emergency:

Name: ______________________________________________________  Phone No.:  ___________________

Name: ______________________________________________________  Phone No.:  ___________________

Please check below if it is known to you that your child has any impairment as listed below:

     Vision |      Speech |      Hearing

If yes, what has been done to correct the condition? __________________________________________________________________________________________

Past illnesses: Check those the child has had and give approximate dates:
   Chicken Pox    |    Asthma    |    Measles    |    German Measles   
   Rheumatic Fever    |    Hay Fever    |    Diabetes    |    Epilepsy   
   Whooping Cough    |    Scarlet Fever    |    Mumps    |

Other serious or severe illnesses or accidents? _______________________________________________________________________________________
Does child have allergies? Yes      No   

To what? __________________________________________

Is your child taking any medication other than vitamins? __________________________

Is there anything concerning the general health of your child that the school should know about?_________________________________________________________________________________

No. of Children in Household: __________
Sibling/s Date/s of Birth: __________________________________________________________________


3-5 Year Old Classes

The Staff of LR Preschool will not dispense any medication without a prescription and written instructions from a doctor, as well as written permission from the parent / legal guardian.  This procedure is as per the insurance guidelines of the school’s insurance policy.  This policy is for the protection of your child and our staff.

_______________________________________________             ______________________________
                   Child’s Name                                        Class

_______________________________________________             ______________________________
     Signature of Parent / Legal Guardian                   Date


3-5 Year Old Classes

Child's Name:_________________________________________________ Date of Birth _________________

Address: _________________________________________________________________________________


Phone No.: __________________________________________

According to the New York State Public Health Law, Section 2164, it is required that your child receives certain immunizations.  Please have your physician complete and sign this form as proof of immunization.  This must be returned to us within   two (2) weeks of registration.  Thank you.

DPT  (list all dates)  _______________________________________________________________________
HIB (list all dates)  ________________________________________________________________________

Polio (list all dates) ________________________________________________________________________

MMR ___________________________________________________________________________________

HEP B (list all dates) _______________________________________________________________________
Varivax or Varicella ________________________________________________________________________

Pneumococcal (PCV) or Prevnar (list all dates)__________________________________________________

Please check if child is up-to-date on all immunizations

Is there anything concerning the general health of this child that the school should know about?


It is recommended that each child be given a complete physical examination prior to entering preschool and that his immunizations be brought up to date at this time.  Before entering school, children are required to have proof of the following immunizations:  DPT, Polio, Measles, Rubella, Mumps & HiB as required by the New York State Board of Health.

______________________________________                                _________________________________
       Physician's Signature            Date
          -  Web Page  | Electronic Media  | Newspapers  |  Brochures –
     3-5 Year Old Classes


________________________________________________                            ______________________
     Student Name                    Class

I hereby consent to having ________________________________________’s picture appear in electronic media or print publications that LR Preschool might choose to release.  I understand that his / her picture may be on display in accordance with any of the above mentioned activities.  I further acknowledge that my child’s name may or may not be used in connection with his / her picture.

I hereby agree on behalf of the above named student and with agreement of his / her parent or legal guardian to waive any claims against LR Preschool which may arise from the use of any pictures used in accordance with a LR Preschool publication.

If at any time, I want my child’s photograph to be removed from the LR Preschool web site or other electronic media, I acknowledge that it is my responsibility to inform, in writing, the Executive Board of this decision.

    Signature of Parent / Legal Guardian


3-5 Year Old Classes

Child’s Name: ___________________________________

Please put an X next to what applies to your child:

Potty Training      | Potty Trained      | Pull Ups     

I authorize LR Preschool to escort my child to the bathroom, keeping in mind, my child is able to use the bathroom and wipe independently. I further understand that if my child should have any bathroom accident, I will be called to come and assist my child with changing of clothes.

____________________________________________ _________________________
  Signature of Parent / Legal Guardian           Date


_____________________________________ has my permission to go on any trips scheduled as (child’s name) part of the activities of the LR Preschool while he / she is enrolled in the school. I understand that it is my responsibility as the parent / legal guardian to arrange transportation for my child for each excursion.

____________________________________________    ______________________________
  Signature of Parent / Legal Guardian          Date
3-5 Year Old Classes

Dear Parents,


These General Membership Meetings present an opportunity for you to learn about your child's curriculum.  You are able to become informed about upcoming events.  It is also an opportunity for you to meet your child's teacher and talk about your child's progress.  At these meetings, you are able to get information about fundraisers and obtain general information about the school.  It is a great chance to become involved in your child's school and meet other parents.

The first general parent meeting will be held in September at the pre-school. Please also note that there will be 4 additional mandatory parent meetings during the year.  All are Thursday evenings and will start promptly at 7:30 p.m. at the pre-school, so please make arrangements accordingly.  Parents, please make childcare arrangements.

As stressed above, these general membership meetings are extremely important. There will be a $10.00 fine if you do not attend a meeting or do not have a non-member represent you as outlined in our Bylaws.  All members are required to put in writing any excuses for non-attendance prior to the meeting date and drop them off in the Chairperson's mailbox.

** A copy of the Bylaws is available at the preschool.  The Bylaws are also available on our web site at  **

Thank you for your attention in this matter.


The Executive Board

I acknowledge and accept my obligations for the General Membership Meetings.

        Signature of Parent / Legal Guardian

Student's name:  ______________________________________

Class:          _________


Dear Parents,

As per our school policy, the doors will be opened at 9:25 A.M. for drop off and 11:55 A.M. for pick up.   For the 2 year olds, it will be opened at 9:40 A.M. for drop off and 11:40 A.M. for pick up.  The door will not be opened prior to 9:25 am.  Please make plans accordingly.

It is important that class starts on time, so please make every effort to arrive on time for your child's scheduled start time.  The teachers only have a limited amount of time with the children, and every moment matters.

If you are the parent of the day, you will need to ring the bell when you arrive at the school.

Latecomers are to either ring the school's doorbell or call the classroom telephone, and a staff member will open the door.  Please be patient when ringing the bell or calling, the teachers are all working with the children.

We would appreciate cooperation with our procedure.

If there are any questions, please feel free to contact our Chairperson.

Thank you for your consideration in this matter.


The Executive Board


Dear Parents,

Attached you will find a STUDENT RELEASE FORM.

Our teachers are diligent in checking the ID's on pick up time when they are not familiar with an individual. Please assist the teachers by informing them when there is a different person who will be picking up your child.

At this time, we would like a written list of those individuals and if you know the particular days in which they will be coming, i.e. Wednesdays, please approach the teachers and let them know as soon as possible.

If someone is coming to pick up your child and they are not on this list, the child will NOT be released to them.  If there are any changes during the year, please notify the teachers and they will give you another form to fill out.


The Executive Board

         3-5 Year Old Classes

Student's Name: _________________________________________ Class: ____________

Please list, OTHER THAN YOURSELF, individuals that you allow to pick up your child from school.  As a courtesy, please let your child's teacher know ahead of time that someone other than yourself will be picking up your child.  Please let this individual know that his / her ID will be requested at pick up time.    

1. Name: ____________________________________ | Relationship: ________________________________
    Contact Number/s: __________________________ | Pick – up day/s: ______________________________
2. Name: ____________________________________ | Relationship: ________________________________
    Contact Number/s: __________________________ | Pick – up day/s: ______________________________
3. Name: ____________________________________ | Relationship: ________________________________
    Contact Number/s: __________________________ | Pick – up day/s: ______________________________
4. Name: ____________________________________ | Relationship: ________________________________
    Contact Number/s: __________________________ | Pick – up day/s: ______________________________
5. Name: ____________________________________ | Relationship: ________________________________
    Contact Number/s: __________________________ | Pick – up day/s: ______________________________