Child's Information
First name
*
Last name
*
M.I.
Child's Birth Date
*
-
Month
-
Day
Year
Date
Male or female?
Female
Male
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Preferred Start Date
*
-
Month
-
Day
Year
Date
Days of the week required
*
Monday
Tuesday
Wednesday
Thursday
Friday
Estimated Drop Off and Pick Up Times
*
Parent's Information
Parent's/Guardian's name
*
Phone number
*
Place of work
Email address
*
Additional Information
Primary Language
Potty Trained?
Yes
Almost There
No
Still an Infant/Toddler
Do you receive PCOE funding for child care?
Yes
No
Previous Preschool Experience, if so where?
What are you hoping your child gains from attending preschool?
Has your child been vaccinated?
Yes, up to date.
Yes but at our pace.
Not at all
Please list any of the following: Current medications, medication allergies, food allergies, food preferences or chronic health concerns.
How did you hear about us?
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