Application Form

Application Form
Applying for:*

Regular school hours (M T TH F) 8:15am-12:45pmExtended After School Care (M T TH F) 12:45pm-3:15pm
Child's Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's First Language*
Last School Attended
If applicable
Parent/Guardian's Information
Parent/Guardian's Name - Primary*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email *
Occupation*
Marital Status

SingleMarriedDivorced
Parent/Guardian's Name - Secondary

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Marital Status

SingleMarriedDivorced
In case of emergency, who will be notified? Please answer the fields below:
Emergency Contact Person*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Health History
If the student have any allergies, please list them down below:
Does the student currently taking any medications? If yes, please list them down below:
Does the student have any medical conditions that you would like to declare?
Questionnaire

About the child
Tell us about your child.*
What are your child's interest? *
Is your child comfortable with parent leaving? *
What are your child's strengths?*
Do you have any concerns about your child's development? Social, Emotional, Physical, or Cognitive*
Reminder
INTERVIEW. Once application is submitted Little Schoolhouse will call and schedule a interview with the parent and child as part of pre-admission process.
Primary Parent/Guardian Signature
Secondary Parent/Guardian Signature
Date Signed*

MonthDayYear
Date
Should be Empty:

Application Form

Parent/Guardian's Information

Health History

Questionnaire

Reminder