Office use only
Date received _______
Fee SesI SesII Both
Health form_________
Insurance __________
PRESCHOOL APPLICATION
Date _____________________
PLEASE CIRCLE ONE
My child will attend …… Tuesday/Thursday-4/5 year old program
or
Wednesday/Friday-3 year old program
PLEASE CIRCLE ONE
I am signing my child up for…
Session I
Session II
Both Sessions
September-December
February-May
$240
$125.00
$125.00
Child’s name ____________________________________________________
Last
First
Child’s birth date _____/______/______
Please circle - Male or Female
Home address ___________________________________________________
___________________________________________________
Home telephone__________________________________________________
E-mail address __________________________________________________
Mother’s name ______________________ cell number ___________________
Father’s name _______________________cell number ___________________
Please provide us with 3 emergency contact numbers where someone can be
reached during preschool hours (8:50-11:00).
1st contact
2nd contact
3rd contact
Name _______________________ number _________________
Name _______________________ number _________________
Name _______________________ number _________________
(Don’t forget the back)
Any allergies, if so list ____________________________________________
Any medical conditions we need to be aware of, if so list ___________________
_____________________________________________________________
Please list siblings of child
Name
Age
__________________________
_____
__________________________
_____
__________________________
_____
__________________________
_____
__________________________
_____
In the space below tell us a little about your child, anything special we should know
about him or her, a funny story or just some facts. (It is ok to brag)