MIDDLEBOROUGH INTEGRATED PRESCHOOL PROGRAM
APPLICATION FORM FOR WAITING LIST
Child’s Name:
Mother’s Name:
Address:
Home Phone:
Siblings:
Date of Birth:
Father’s Name:
M or F (circle)
Work/Cell Phone:
Age:
Age:
1.
Has your child ever had a daycare/preschool experience? Yes
If yes, please describe:
2.
Does your child have any allergies? Yes
If yes, please describe (please be specific):
3.
4.
Does your child take medication on a regular basis? Yes
What are your child’s favorite activities?
5.
Describe your child’s special strengths:
6.
How did you learn about Middleborough’s Integrated Preschool?
No
No
No
I VERIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS ACCURATE.
Signature of Parent/Guardian
Date
*Families of children applying for placement on the 2014-2015 waiting list will be required to show proof of residency
(e.g., utility bill) and official birth certificate at the time of application; children will not be added to the waiting list
without these documents
(Initial acknowledging requirement)
Please return completed form to:
(submit this page only; residency and other
documents will be verified and collected
at the time of screening)
Mr. Michael Breault, Principal
Memorial Early Childhood Center
219 North Main Street
Middleborough, MA 02346
Applicants are placed on the waiting list in the order in which their paperwork is received. Families will
be contacted when an opening arises and screening will be scheduled as the next step in the process.
__________________________________________________________
For office use only
Date Received:
Position on Waiting List:
Date contacted:
Child’s Name: