Ryves Preschool Application

Ryves Preschool Child Application

Please complete the following information for your child.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Sex REQUIRED Please fill out this field.

Age REQUIRED Please fill out this field. Please enter valid data.

Race REQUIRED Caucasian Black or African American Hispanic or Latino American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Please fill out this field.

Language Spoken at Home REQUIRED Please fill out this field. Please enter valid data.

We require that all students be potty trained. Is your child potty trained? REQUIRED Yes No Please fill out this field.

Are you currently residing at Bethany House or another shelter program? REQUIRED Yes No Please fill out this field.

Parent/Guardian Contact

Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.

Home/Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Address REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.

Home/Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Address REQUIRED Please fill out this field. Please enter valid data.

Waiver of Responsibility & Photo Consent

By checking I agree, I give my permission for my child to participate in all activities held at or sponsored by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, the Archdiocese of Indianapolis, or any agent thereof. I also give my permission for my child to participate in any field trip or outing sponsored by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or their agents. I also give my permission for my child to be used in any promotional material (videotaped, photographed, or audiotaped) by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, the news media, or any of the above-designated agent(s). I realize that the above-mentioned media may be used for publicity or educational purposes. I also give my permission for my child to be interviewed, photographed, video or audiotaped by the news media. I also give my permission for my child to participate in support groups and counseling sessions provided by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or any agent thereof. I also permit my child to participate in any written or verbal surveys conducted by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or any designated agent or collaborator. I realize that activities at Ryves Youth Center at Etling Hall are educational, recreational, and supportive in nature. I also realize that outside organizations provide activities and field trips for members of Ryves Youth Center at Etling Hall. I give my permission for my child to participate in these activities and field trips. I will not hold Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or any agent thereof responsible for any accident happening to my child. I also give my permission for my child to receive emergency first aid and medical treatment in case of accident or illness.

I Agree Please select this field.