Application for EnrollmentCGAdmin2021-07-13T20:41:15-04:00 Child's Name:* Gender:* Date of birth:* MM slash DD slash YYYY Proposed Date of Entrance:* I am applying for:Three Full Days Select All Monday Full Day - 8am-4:00pm Tuesday Full Day - 8am-4:00pm Wednesday Full Day - 8am-4:00pm FAMILY INFORMATIONParent 1:* Full Address:* Please provide your full street address, town, state and zip codeHome Phone:Cell Phone:*Email:* Employer:* Position:* Work Address:* Work Phone:* Parent 2:* Address:* Please provide your full street address, town, state and zip codeHome Phone:Cell Phone:*Email:* Employer:* Position:* Work Address:* Work Phone:* Child lives with (Please check all that apply)* Mother/s Father/s Partner Stepmother Stepfather Parents Separated Parents Divorced Mother Deceased Father Deceased Specify custody arrangements, if any: If two households, mailings should be sent to: Parent 1 Parent 2 Please list the names and ages of other members of the household:Name: Date of Birth MM slash DD slash YYYY Relationship to child: Name: Date of Birth MM slash DD slash YYYY Relationship to 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.)*Has your child ever had any sensory, movement or REACH evaluations or any educational or psychological testing?* Yes No If yes, please describe and attach copies of the reportIf yes, please describe and attach copies of the reportDoes 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 A non-refundable application fee of $25 must accompany this application. The fee can be paid by Credit Card or PayPal using the button at the bottom of this page. We will then call you to set up an appointment. The Cottage Garden does not discriminate on the basis of race, color, religion, sexual orientation, or national origin in its admissions or educational policies Parent 1 Signature:* Date:* MM slash DD slash YYYY Parent 2 Signature:* Date:* MM slash DD slash YYYY HiddenApplication Received on: HiddenApplication Fee Received on: HiddenInterview 1 scheduled for: HiddenInterview 2 scheduled for:
