Preschool Application

Preschool Application

Today’s date______

Child’s Name: ______Birth date:______

Family Information (or custodial guardian)

Name:______Relationship:______

Is this child a foster child? YesNo

Address:______

Length of time at address:______

Home Phone:______Cell Phone:______

E-Mail Address______

Graduated High School (circle one):YesNo

Age at birth of child:______Marital status when child was born:______

Employer:______Phone:______

Family Information 2 (or custodial guardian)

Name:______Relationship:______

Address, if different:______

Length of time at address:______

Home Phone:______Cell Phone:______

E-Mail Address:______

Graduated High School (circle one): YesNo

Age at birth of child:______Marital status when child was born:______

Employer:______Phone:______

Living Situation

Describe your current living situation, including any recent changes:______

______

Describe any disruptions or stresses your family is currently experiencing (illness, separations from a parent, drug or alcohol abuse, physical or emotional abuse, etc.) or serious situations from your child and family’s past: ______

______

Please list all the addresses where your child has lived in the past two years (include dates):

1.______

2.______

3.______

4.______

5.______

Information to help us get to know your child and family

These are things I want my child to learn in preschool this year:

1.______

2.______

3.______

4.______

5.______

My child is good at:______

My child needs help with:______

Names of brothers and sisters and ages and school(s) attended:______
______

______

Other people who live in our household are (names and relationships):______

______

Language

My child understands and speaks English (circle one):YesSomeNo

I have concerns about my child’s speech (circle one):YesNo

If yes, please explain:______

______

Languages spoken in our home:______

Educational Plan/Support

My child has an Individual Family Service Plan (IFSP), 504, or Individualized Education Plan (IEP) (circle one): Yes No If yes, which one? IFSP 504 IEP

If yes, I have provided a copyof my child’s plan to the school. (NOTE: This application will not be considered complete until the plan has been received and reviewed by the school.)

Social

I have concerns about my child’s behavior (circle one):YesNo

I have concerns about my child’s social skills (circle one):YesNo

Has your child been excluded or expelled from other preschool/ child care programs or community activities due to behavior or emotional concerns? Yes No

If yes, please explain______

______

My signature indicates that the information I have provided in this application is true and correct.

______

SignatureDate

Feel free to include any additional information below or on the back of this form: