Application for Admission Step 1 of 2 50% Application for AdmissionChild’s Name* First Last NicknameBirthdate (MM/DD/YYYY)* Date Format: MM slash DD slash YYYY Age*Gender*Address* Street Address City State / Province / Region ZIP / Postal Code Parent/Guardian #1 Name* First Last Relationship to child*Address* Same as child's address Street Address City State / Province / Region ZIP / Postal Code Home Phone*Cell Phone*Parent Email* Parent/Guardian #2 Name* First Last Relationship to child*Address* Same as child's address Street Address City State / Province / Region ZIP / Postal Code Home Phone*Cell Phone*Parent Email* Siblings Information:Siblings NameAge With whom does the child live?*Both ParentsMotherFatherDoes anyone care for your child, other than the parents?*YesNoIf so, please explain*Child’s previous school or group experienceWhich program are you applying for?*Preschool (Ages 2½ – 5 years)Grade 1Grade 2Grade 3Class choice:* 3 Days Morning Session (9-11:30 AM) 3 Days Afternoon Session (12:30-3:00 PM) 4 Days Morning Session (9-11:30 AM) 4 Days Afternoon Session (12:30-3:00 PM) 5 Days Morning Session (9-11:30 AM) 5 Days Afternoon Session (12:30-3:00 PM) 3 Full Days 4 Full Days 5 Full Days Select Days* Select All Monday Tuesday Wednesday Thursday Friday How did you hear about us*FriendFacebook/InstagramGoogleMailingNewspaperPlease check 8 to 10 words that best describe your child:* Orderly Helpful Artistic Inquisitive Sociable Diligent Neat Peaceful Caring Confident Calm Content Playful Sensitive Methodical Talkative Studious Timid Active Attentive Quiet Cheerful Daring Gentle Curious Lively Reserved Logical Determined Happy Builder Nature Loving Free Spirited Enthusiastic Responsible Individualist History:Did you experience a normal pregnancy?*YesNoWas your pregnancy full term?*YesNoHas your child been hospitalized?*Does your child take any medications?*YesNoIf yes, please indicate dosage and frequency:Does your child have any allergies?What is your child’s primary language?What language is spoken at home?Has your child ever had a vision, speech or hearing evaluation?*YesNoIf “yes” please provide information*What form of discipline do you use at home?*PraiseTime outReward SystemPaddleLoss of PrivilegesWhat self-help skills has your child mastered?* Undress self-Dress self-Feed self Use of toilet Hand washing Nose blowing Does your child follow a morning/evening routine?*YesNoDescribe your child’s daily routine:*AM: PM:Does he/she nap?*YesNoLength*Do you have meals together as a family?*YesNoHow much time does your child spend: Watching TV*How much time does your child spend: Computer/Video games*Does your child pronounce words accurately?*YesNoDoes your child know the alphabet?*YesNoDoes your child follow directions?*YesNoDoes your child write name?*YesNoDoes your communicate effectively?*YesNoComments
