Application for Admission
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Mother's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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Emergency Contact #1
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a backup care provider?
*
Please Select
Yes
No
If yes, please provide their contact information:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Preferred Start Date
*
-
Month
-
Day
Year
Date
Monday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Tuesday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Wednesday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Thursday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Friday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
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Your Child's Health
CHILD'S HEALTH RECORD: A copy of your child's immunization records and current physical will be required.
How is your child's overall health?
*
Please Select
Good
Fair
Poor
Doctor's Name
*
First Name
Last Name
Doctor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Dentist's Name
*
First Name
Last Name
Dentist's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are your child's immunizations up to date?
*
Please Select
Yes
No
Does your child have any known allergies (seasonal, medication, food, etc.)?
*
Are you concerned that your child may be prone to any types of allergies? Please describe:
*
Does your child have any medical conditions that we should be aware of?
*
Does your child have any problems with any of these?
*
Constipation
Convulsions
Diarrhea
Fainting spells
Frequent colds
Frequent ear infections
Frequent sore throats
Lice
Ringworm
Soiling
Stomach upsets
Urinary problems
Worms
None of the above
Has your child had any of these diseases?
*
Asthma
Bronchitis
Chicken Pox
Diabetes
Heart diseases
Hepatitis
Impetigo
Measles
Polio
Scarlet Fever
Tuberculosis
Whooping Cough
None of the above
Does your child have any speech, hearing or visual problems?
*
Are there any restrictions to play or activities?
*
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About Your Child
Has your child ever been in child care before?
*
Please Select
Yes
No
If yes, what type of child care setting have they attended?
Child care center
In-home daycare
Family member
Other
Was it a positive experience?
Please Select
Yes
No
How does your child feel about attending preschool and being left by his/her parents?
*
Are there any recent traumatic situations the child has been exposed to, such as a death in the family, divorce, new siblings, etc.?
*
What is your normal method of discipline?
*
What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.?
*
Are there any food restrictions?
*
What is your child's favorite food?
*
What foods does your child dislike?
*
Can your child be relied upon to indicate bathroom wishes?
*
Please Select
Yes, independent
No, needs assistance
What words does your child use for bowel movements and urination?
*
What time does your child awaken?
*
What time does your child go to sleep at night?
*
Do they sleep through the night?
*
Please Select
Yes
No
Sometimes
Does your child sleep in a bed, crib or other?
*
Please Select
Bed
Crib
Other
Are there any siblings? Please name them and specify ages and gender:
*
Has your child had experience playing with other children?
*
What languages are spoken at home?
*
Does your child have any security objects such as a blanket, stuffed animal, etc?
*
What are your child's favorite activities, toys, books or games?
*
Are there any other comments or information you would like to share?
Any specific concerns?
Submit
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