PLEASE INDICATE 1ST AND 2ND CHOICE FOR CLASS PLACEMENT.

1ST CHOICE
1-Day Program
2-Day Program
3-Day Program        AM    PM
4-Day Program        AM    PM

2nd CHOICE
1-Day Program
2-Day Program
3-Day Program        AM    PM
4-Day Program        AM    PM

AGE PREFERENCE
Everything Nice (2 1/2 before Oct. 1)
Pre-School Class (3 before Oct. 1)
Pre-Kindergarten Class (4 before Oct. 1)

Whenever possible we will try to honor first preferences.  Final placement is subject to class availiability.

Child's Name  

Last        

            
First              

Nickname (if any)

Address
Street                                        City                                        Zip
 

Birthday

Home Phone Number

Cell Phone Number

Mother's Name                     Father's Name

Mother's Address (if different from child)
Street                                        City                                        Zip
 

Father's Address (if different from child)
Street                                        City                                        Zip
 

Mother's Occupation

Mother's Business Address
Street                                        City                                        Zip
 

Business Phone

Father's Occupation

Father's Business Address
Street                                        City                                        Zip
 

Business Phone

Please list other children in family (names and ages)

ALTERNATE PERSON WE CAN CONTACT IN AN EMERGENCY
Name                                      Relation to Child

Address
Street                                        City                                        Zip
 

Phone

Doctor's Name                       Phone

Address
Street                                        City                                        Zip
 

Has your child had any previous Pre-School experience? Please specify.

Please use the space below to provide with any additional information you deem necessary in helping us plan a meaningful program for your child.