Prospective Parent Pre-application Information Form

Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Name *

First Name

Last Name

Parent's Phone *

(###)

###

####

Early Childhood Enrollment

Early Childhood (3 to 6 years old)

Pre-school AM Session (8:30 - 11:30)

Pre-school Full Day (8:30 - 3:00)

Kindergarten AM Session (8:30 - 11:30)

Kindergarten Full Day (8:30 - 3:00)

Elementary Enrollment

Full Day Elementary (6 - 12 years old)

Lower Elementary (Grades 1 - 3)

Upper Elementary (Grades 4 - 6)

Does your child have any special needs that we should be aware of?

Please check all that apply.

Allergies

Special Diet

Medical Problems/Treatments

Psychiatric Problems/Treatments

Physical Impairment

Hearing Impairment

Speech Impairment

Visual Impairment