Application for Preschool Enrollment

Application for Preschool Enrollment

Child’s Name: ______Gender: ______Date of Birth: ______

Home Address: ______

Typical Daily Hours: ______- ______

Family Information:

Parent/Guardian 1: ______

Home Phone: ______

Home Address: ______

Cell Phone: ______

Email: ______

Employer: ______

Work Address: ______

Work Phone: ______

Parent/Guardian 2: ______

Home Phone: ______

Home Address: ______

Cell Phone: ______

Email: ______

Employer: ______

Work Address: ______

Work Phone: ______

Please specify any custody arrangements: ______

______

Siblings:

Name: ______Date of Birth: ______

Is your child toilet trained? yes no comments: ______

Describe your child’s experiences outside of home life-babysitter, playgroup, playmates, grandparents, previous school experience: ______

______

Has your child or another child in the family attended a Mariposa program in the past?

______

How did you hear about us? ______

Do you receive Child Care Assistance from DHS? yes no

If yes, do you have a current CCAP certificate? yes no

Is your child currently receiving special education services? yes no

Has your child received special education services in the past? yes no

If yes, please provide the most current copy of your DHS certificate number and your child’s education services.

What languages are spoken in your home? ______

Comments: Is there anything else you would like to share with us about your child?

______

Parent Signature ______Date: ______

A non-refundable application fee of $ 25.00 must accompany the application.

Please make checks out to The Mariposa Center. Return to: The Mariposa Center PO Box 6759 Providence, RI 02940

The Mariposa Center does not discriminate on the basis of race, color, religion, sex, sexual orientation, or national origin in its admissions or educational policies.

------For office use only------

Application Fee Received ______Date Received ____________ Tour Date ______

PO BOX 6759 Providence, RI 02940 401.228.8702