2024-2025 Preschool Registration

Child Name*

First NameLast Name

Birthdate*

MonthDayYear

Child's Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email*

example@example.com

Parent/Guardian Home/Work Phone:*

Please enter a valid phone number.

Parent Guardian Cell Phone:*

Please enter a valid phone number.

Relationship to the child*

Parent/Guardian Name

First NameLast Name

Parent/Guardian Email

example@example.com

Parent/Guardian Home/Work Phone:

Please enter a valid phone number.

Parent/Guardian Cell Phone

Please enter a valid phone number.

Relationship to the child

Parent/Guardian Martial Status*

Custodial/ Visitation Arrangements:

Emergency Contact*

First NameLast Name

Relationship to child:

Phone Number*

Please enter a valid phone number.

Who lives in the household?*

Names and ages of other children in the family and school’s attending? *

What languages are spoken in the home?*

Describe any previous preschool/daycare experiences. *

What are your child's interests?*

In order for our teachers to best meet your child’s education needs, please describe any conditions which affect how your child learns?*

Does your child have any difficulty seeing, hearing, walking or speaking? *

Parent/Guardians’ evaluation of child’s health: *

Does your child have allergies or dietary needs?*

Does your child take prescription medication for any physical, emotional, or behavioral issues? If so, please describe:*

Are there any other health issues we should be aware of? *

Pediatrician*

Dentist*

If your child is accepted, additional paperwork and deposit must be submitted to KiDiMu within 15 days. Please initial. *

2024 - 2025 Preschool Application