Preschool Enrollment Form

Child's Information
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
Gender *

Female Male

Preschool Attendance Information
Desired Start Date *

Month Day Year
Date
Additional Information Regarding Attendance

Parent/Guardian 1 Contact Information
Name *

First Name Last Name
Email *
example@example.com
Relationship *
Mother, Father, etc
Mobile Phone Number *

Area Code Phone Number
Address *

Same as Child Different Address
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation:
Employer:
Work Phone Number

Area Code Phone Number
Employer's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian 2 Contact Information
Name

First Name Last Name
Is this person to be included as an Emergency Contact?

Yes No
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number

Area Code Phone Number
Address

Same as Child Different Address
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation:
Employer:
Work Phone Number

Area Code Phone Number
Employer's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contacts
Additional Emergency Contact 1 *

First Name Last Name Relationship
Phone Number *

Area Code Phone Number
Additional Emergency Contact 2

First Name Last Name Relationship
Phone Number

Area Code Phone Number
Please list names of additional people authorized to pick up your child:

Program Questions
If your child currently attends a child care program, please include the name of the program:
Please list siblings names/ages:
Does your child take a nap?
Is your child toilet trained?

Medical Information
Please list your child's allergies and/or medications:
Child's Physician:
Physician's Phone Number:
Any additional important medical information:

For the St. Mark Preschool Office
What time of day is the best to call?
Are you interested in scheduling a tour of the school?

Yes No

Signatures
I understand that there is a one-time, non-refundable fee of $75.00 to add my child to the wait list and my child will not be added to the wait list until this fee has been paid.

*Application fees may be paid via cash, check, or Visa/Mastercard. To pay with card, please call 434-293-0792 during normal business hours. Cash payments may be dropped off during normal business hours. Checks should be made out to St. Mark Lutheran Preschool and must note the child's name. Checks may be dropped off in person during normal business hours or mailed to:

St. Mark Lutheran Preschool

100 Alderman Road

Charlottesville, VA 22903
Signature *

Clear
Printed Name *
Date *

Month Day Year
Date
I, the undersigned, attest that the information contained herein is accurate and current. As legal parent/guardian, I authorize my child to attend St Mark Lutheran Preschool.
Signature *

Clear
Printed Name *
Date *

Month Day Year
Date
Should be Empty:

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