2019-2020 PRESCHOOL APPLICATION FORM


TODAY’S DATE_______________________________


CHILD'S NAME ___________________________________________________________________________________________________________________
                                                     (FIRST)                                      (MIDDLE)                                             (LAST)

HOME ADDRESS __________________________________________________________________________________________________________________
                                                         (NO. & STREET)                                               (TOWN)                                                 (STATE/ZIP CODE)

HOME TELEPHONE _________________________BIRTH DATE_________________ AGE AT ADMISSION _______

FATHER'S NAME ______________________________ MOTHER'S NAME ____________________________________

FATHER’S CELL #_____________________________ MOTHER’S CELL#____________________________________

BUSINESS ADDRESS __________________________    BUSINESS ADDRESS ________________________________

BUSINESS TELEPHONE #_______________________   BUSINESS TELEPHONE #_____________________________

HOURS AT WORK _____________________________ HOURS AT WORK ________________________________    

ALLERGIES/SPECIAL DIET _________________________________________________________________________

INDIVIDUAL HEALTH PLAN FOR A CHILD WITH A CHRONIC HEALTH CONDITION? _______ IF YES, PLEASE ATTACH.

ANY CUSTODY AGREEMENTS, COURT ORDERS AND RESTRAINING ORDERS.______ IF YES, PLEASE ATTACH COPIES.

LIMITATIONS OR CONCERNS._______________________________________________________________________

PLACE OF BIRTH­­ _________________OTHER MEMBERS OF HOUSEHOLD ________________________________

SEX ______ HGT. ______ WGT. _____ HAIR COLOR ________EYE COLOR__________

E-MAIL ADDRESS ___________________________________________ PRIMARY LANGUAGE __________________

NATIONAL ORIGIN _________________ IDENTIFYING MARKS ____________________________________________

CHILD'S PEDIATRICIAN _______________________________________ TELEPHONE #________________________

DAYS ATTENDING (CHECK ALL THAT APPLY):

MONDAY _______     TUESDAY ________     WEDNESDAY ________   THURSDAY_________   FRIDAY_________
__
SESSION ATTENDING (CHECK ONE):

MORNING _________   AFTERNOON _________    FULL DAY __________   EXTENDED DAY _________

IMPORTANT: A NON-REFUNDABLE REGISTRATION FEE OF $50.00 IS REQUIRED TO RESERVE A SPACE FOR CHILD’S FIRST YEAR, $35.00 FOR A CHILD’S SECOND  OR  THIRD YEAR. ONE MONTHLY TUITION PAYMENT FOR NEWLY ENROLLED CHILDREN IS DUE WITH THIS FORM.  A SECOND MONTHLY TUITION PAYMENT IS DUE APRIL 1, 2019. NOTE: These two payments are non-refundable.  The first tuition payment for children returning for a second or third year is due MAY 1, 2019. The second payment is due JUNE 1, 2019. These two payments are non-refundable.

I HAVE READ, UNDERSTAND, AND AGREE TO THE TUITION PAYMENT POLICY OF DOLLY’S NURSERY SCHOOL.

PLEASE SIGN & DATE____________________________________________________________    /________________
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