Child's Name    Date of Birth

Previous Preschool Experience:

Parent's/Guardian Name

Complete Mailing Address
(Include Zip Code)

Subdivision

Parent Information:

Phone Number    Daytime Phone Number

E-mail

 Marital Status:  Single      Married       Divorced

Annual Family Income:
Yearly     Monthly    Weekly

 Parent(s) age at birth of child

 Child’s birth weight

 Please describe any complications during pregnancy or birth of child (text area) 

 Check any area of concerns you may have concerning your child’s development. 
        Speech       Hearing       Vision
        Other: (explain)
                 

 Has your child had/or still have tubes in his/her ears? Yes  No   If yes, at what age?

 Does your child have any allergies? Yes   No  
          If yes, please explain:
                 

Is your child potty trained?  Yes    No 

Primary Language Spoken in home

Child’s primary language

Father’s occupation/place of employment

Mother’s occupation/place of employment  

Number of people living in house?    Number of children    Number of adults

 Are all members of household related Yes   No

  ** Any additional information you may wish to share to help determine eligibility **