One Day Visit Pass Application
Fill out this form before coming to our space.
Child's Information
Child's Name
First Name
Last Name
Gender
Female
Male
Other
Date of Birth
-
Month
-
Day
Year
Etnicity
White
Black
Hispanic
Asian
Not want to specify
Other
Child's Living Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any relevant information you want to add.
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship with the child
Mother
Father
Grand Parents
Other relatives
Guardian
Other
Other Information for the School to know
Has the child attend any other preschool previously?
Yes
No
Please give details
Location, reason for changing school
Please select the ones if you suspect
Delay in speech and language skills
Delay in development skills
Delay in motor/physical development
Delay in social/behavioral skills
Other
Please select any medical and/or psychological diagnoses the child currently has
Astma
Autism / PDD
Speech Disorder
Vision Problems
Birth Injury
Behavior Diagnosis
Hearing Problems
Heart Problems
Physical Impairment
Seizures / Epilepsy
Traumatic Brain Injury
Genetic Disorder
Allergies
There is no diagnosis
Other
Please give details
Second Language Background Information
Does your family have a Latino background? If so, please specify.
Yes
No
Please give details
Who in your household speaks Spanish regularly?
Mother
Father
Grand Parents
Other relatives
Aunt-uncle
Other
If Spanish is not spoken at home, who will be responsible for helping your child learn the language?
Mother
Father
Grand Parents
Other relatives
Aunt-uncle
Other
What are your goals in raising a bilingual child?
Have you actively exposed your child to the Spanish language before?
Yes
No
On average, how many minutes per day do you dedicate to practicing Spanish with your child?
Are you aware of your child's proficiency level in the Spanish language? If so, please describe their skills.
Date
-
Month
-
Day
Year
Submit
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