Preschool Application for Admission

Student Name:  

Date of Birth:

Gender Select Male Female

Age of student on start date: Years   Months

Student Address:

Street

City State Zip code

Primary Doctor: Phone #

Disabilities or limitations? Select Yes No

If yes please explain:

Medical concerns:

(ADD/ADHD, asthma, allergies, diabetes, etc): Select Yes No

If yes, please explain

Parent Information

Mother/Guardian Name:

Street

City State Zip code

Mother Email:

Phone #:

Occupation: 

Work #: 

Language spoken at home:  

Father/Guardian's Name:

Street

City State Zip code

Father Email:

Phone #:

Occupation: 

Work #: 

Language spoken at home:  

Additional Information

Please select the preschool schedule are you applying for…

Full Time: Select 8:30am-3:00pm 8:30-11:30 am 12:00-3:00 pm No preference/ either

Part Time:  Select 8:30-11:30 am Mon., Wed., & Fri. 12:30-3:00pm Mon., Wed., & Fri. 8:30-11:30 am Tues. & Thurs 12:30-3:00 pm Tues. & Thurs.

Extended Day Child Care is also available for parents that need a later pick time. 

Would you be interested in this service?  Select Yes No

Name and age of siblings:

Brother(s):

Sister(s):

About Your Child:

Has your child been cared for by anyone other than parents?  Select Yes No

Has your child previously attended a day care center?  Please_Select Yes No

Does your child use the restroom independently?  Select Yes No

Does your child need help dressing or undressing?  Select Yes No

Does your child take a nap? Select Yes No

Does your child have any fears? Select Yes No

Favorite games: 

Favorite toys:

Favorite books:

Favorite TV shows:

Favorite outdoor activities: 

Parent Digital Signature 

Today's Date: