Child's Name
*
First Name
Last Name
Gender
*
Date of Birth
*
MM
DD
YYYY
Proposed Date of Entrance
*
I Am Applying For:
Select as many that applies.
Parent's Name
*
First Name
Last Name
Full Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Cell Phone
*
(###)
###
####
Email
*
Employer
*
Position
*
Work Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Work Phone
*
(###)
###
####
Parent #2's Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Cell Phone
*
(###)
###
####
Email
*
Employer
*
Position
*
Work Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Work Phone
*
(###)
###
####
Child Lives With...
*
Please check all that apply.
Specify Custody Arrangements, If Any:
If two households, mailings should be sent to:
Parent 1
Parent 2
Please list the names, ages, and relationships to the child of other members of the household:
Please state the name of another member of the household:
Please state the date of birth of another member of the household:
Please state the household member's relationship to the child:
Please state the name of another member of the household:
Please state the date of birth of another member of the household:
Please state the household member's relationship to the child:
Pets
Has your child been weaned
*
Yes
No
Comments:
Has your child been toilet trained?
*
Yes
No
Comments:
Please describe your child’s experience outside the home (babysitter, playgroup, playmates, grandparents):
*
How often does your child watch TV or videos? Use the computer/tablet/iPad?
*
Are there special considerations you have for your child of which we should be aware? (extra-ordinary events, medical, movement, behavioral or emotional concerns)
*
Is your child taking any regularly scheduled medications? Please specify. (Send records where applicable.)
*
Does your child have any medical allergies?
*
Comments: Is there anything you would like use to know about your child?
*
Please tell us how you heard of our program?
*
Word of Mouth
Friend
Other School
Website
Other
Parent 1 Signature:
*
Date
*
MM
DD
YYYY
Parent 2 Signature:
*
Date
*
MM
DD
YYYY
