Preschool Enrollment Form

SMLP Application for Enrollment

At this time, SMLP is accepting applications for a Summer 2025 start date or later.
Child's Information
Child's Name*

First NameMiddle NameLast Name
Nick Name
Date of Birth*

MonthDayYear
Date
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

FemaleMale
Preschool Attendance Information
Desired Start Date*

MonthDayYear
Date
Additional Information Regarding Attendance
Parent/Guardian 1 Information
Name*

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

Area CodePhone Number
Address*

Same as ChildDifferent Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Employer:
Work Phone Number

Area CodePhone Number
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Information
Name

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

YesNo
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number

Area CodePhone Number
Address

Same as ChildDifferent Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Employer:
Work Phone Number

Area CodePhone Number
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts
Additional Emergency Contact 1*

First NameLast Name
Relationship to Child*
Phone Number*

Area CodePhone Number
Additional Emergency Contact 2

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Please list names and phone numbers of additional people authorized to pick up your child:
Child & Family Information
If your child has attended a day care program, please list the name of the school or center:
Who currently provides daily care for your child? (i.e. nanny/parent/day care)*
Please list siblings names/ages:
Does your child take a nap?*

YesNo
If yes, please note typical start and end times for nap:
Is your child toilet trained? (Not required for enrollment)*

YesNo
If your child is not toilet trained, please describe your preferred approach towards toilet training and any experience your child may have with the toilet:
Developmental Profile

Please tell us as much information as possible to answer each question.
Please tell us about your child's personality and interests:*
Please describe your family's parenting approach (if your child is an infant, please describe what you expect your approach to look like when your child enters their toddler years).*
What are the most important factors to you when considering your child's preschool experience?*
Is there anything else you would like us to know about your family and/or child?*
Medical Information
Please list your child's allergies and/or medications:
Child's Physician:*
Physician's Phone Number:*
Any additional 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?*

YesNo
How did you learn about St. Mark Lutheran Preschool?*
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*

MonthDayYear
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.

Decisions for enrollment are made on a rolling basis, with most enrollment decisions naturally being made by February for the following summer and school year. Upon acceptance, a one-time registration fee of $375 is required to hold your child's spot. We aim to be accessible to all interested families and offer scholarships. We do not descriminate based on religion, race, sexual identity, gender, ethnicity, disability, or family structure. All students of St. Mark Lutheran Preschool must be full immunized to attend. (SMLP does NOT currently require the COVID-19 vaccine.)
Signature*

Clear
Printed Name*
Date*

MonthDayYear
Date
Should be Empty:

SMLP Application for Enrollment

Child's Information

Preschool Attendance Information

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Emergency Contacts

Child & Family Information

Developmental Profile

Medical Information

Signatures