Enter date XX/XX/2021
assigned school based on physical address
SECTION 1: Child Information
Enter date of birth XX/XX/20XX
State File Number
City/State/Country
How well does the child speak English?
Check all that apply.
SECTION 2: Parent/Guardian Information
Parent 1/Legal Guardian
First, Middle, Last
City/State/Country
City/State/Country
How well does Parent 1/Legal Guardian speak English?
Check all that apply.
Parent 2/Legal Guardian
First, Middle, Last
City/State/Country
How well does Parent 2/Legal Guardian speak English?
Check all that apply.
SECTION 3: Living/Physical Address
Enter the physical address of where you live.
SECTION 4: Mailing Address
Enter house number and street or PO Box
SECTION 5: Custody Order
If yes, you MUST provide the school with a copy.
SECTION 6: Household Member Information (Adults & Children)
ADULTS Living in the Household
(Include all adults)
Last name, first name
Business name
Business street, city, state, zip
Adult 2 Living in Household
First, Middle, Last
Business name
Business street, city, state, zip
Adult 3 Living in Household
First, Middle, Last
Business name
Business street, city, state, zip
Adult 4 Living In Household
First, Middle, Last
Business name
Business street, city, state, zip
Adult 5 Living in Household
First, Middle, Last
Business name
Business street, city, state, zip
CHILDREN Living in Household (LIST APPLICANT FIRST, then all other children)
Child 1 (Applicant)
Child 2 Living in Household
Child 3 Living in Household
Child 4 Living in Household
Child 5 Living in Household
Section 7: In Case of Emergency
Who to contact in case of emergency (other than Parent/Legal Guardian)
street number, city, state, zip code
street number, city, state, zip code
Section 8: Child Data
Concerns, observations, risks, medical
If yes, please describe; if no, state none
Check all that apply.
Check all that apply.
For example: Speech, 06/2020, VCU
Check all that apply.
Check all that would apply in an emergency.
Note: If medication must be administered during school hours, we must have paperwork completed by a doctor.
Check all that apply.
Section 9: Family Information
Family information including type, status, and services
Date
Check only one.
Check only one.
Check only one.
Check all that apply.
Section 10: Family Doctor
street number, city, state, zip
Section 11: Family Dentist
street number, city, state, zip
Please read and sign the statement below:
Note: Only a limited number of preschool spots are available; applying does not guarantee acceptance. Preschool is not first-come first-served. Students who are not initially accepted are placed on the waiting list in case a spot opens up during the school year. CERTIFICATION: I certify all of the information I provided is true and correct and all income is reported and submitted. I understand that if any of this information changes, I am obligated to notify the program immediately. I understand deliberate misprespresentation of any of this information will disqualify my child from being considered for a preschool program.
enter first and last name
