Preschool Application
A boutique, play-based preschool for children 18 months to 5 years old.
Child Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Phone Number
*
Date of Admission
*
-
Month
-
Day
Year
Please select desired date of admission.
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Parent Information
Parent A Information
Parent A Name
*
First Name
Last Name
Parent A Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent A Phone Number
*
Please enter a valid phone number.
Parent B Information (if applicable)
Parent B Name
First Name
Last Name
Parent B Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent B Phone Number
Please enter a valid phone number.
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Emergency Contact Information
We will only contact this individual if/when we are unable to first reach a parent.
Emergency Contact Name
*
First Name
Last Name
Relationship to Child
*
Friend, relative, etc.
Emergency Contact Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Phone Number
*
Please enter a valid phone number.
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Authorized Pickup Information
Please provide the name and telephone numbers of person(s) other than a parent who may pick up your child. If you would like to add more than three individuals, please reach out to us directly.
Authorized Pickup A
Auth. Pickup A Name
First Name
Last Name
Auth. Pickup A Phone Number
Please enter a valid phone number.
Authorized Pickup B
Auth. Pickup B Name
First Name
Last Name
Auth. Pickup B Phone Number
Please enter a valid phone number.
Authorized Pickup C
Auth. Pickup C Name
First Name
Last Name
Auth. Pickup C Phone Number
Please enter a valid phone number.
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Medical & Safety Information
Child's Physician
Physician Name
*
First Name
Last Name
Physician Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Physician Number
*
Please enter a valid phone number.
Child's Medical History & Additional Information
Please list any special care needs for your child.
This includes, but is not limited to, allergies, existing illness, previous serious illness and injuries, hospitalizations during the past 12 months, and any medications prescribed for continuous, long-term use
Please provide a food allergy emergency plan for the child, if applicable.
Please provide any additional information, if applicable.
Do you authorize The Rosedale Preschool to obtain emergency care for your child, and/or provide transportation for emergency medical treatment?
*
If so, please sign.
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Application Fee
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Application Fee
$
100.00
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