2025-2026 Preschool Applicaton CHILD'S INFORMATION Child's Name * First Name Last Name Date of Birth * MM DD YYYY Gender Male Female Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Language Spoken at Home English Spanish Other PARENT/GUARDIAN INFORMATION Parent/Guardian 1 * First Name Last Name Relationship to Child Phone (###) ### #### Email Occupation Employer Parent/Guardian 2 (If applicable) First Name Last Name Relationship to Child Phone (###) ### #### Email Occupation Employer EMERGENCY CONTACT Emergency contact cannot be either one of the child's parents/guardians. Name First Name Last Name Relationship to Child Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country MEDICAL INFORMATION Child's Physician Phone (###) ### #### Please list any known allergies: SPECIAL NEEDS & DEVELOPMENTAL INFORMATION Does your child have any food allergies or dietary restrictions? Yes No Does your child take any medications regularly? Yes No Has your child undergone any developmental assessments? Yes No Has your child undergone an occupational therapy (OT), speech therapy (ST), or physical therapy (PT) evaluation? Yes No If a developmental evaluation has not been conducted, would you like to discuss scheduling one? Yes No Are there any concerns you would like to share about your child? Is there any additional information you would like to share about your child? ADDITIONAL INFORMATION Does your child have any previous daycare/preschool experience? Yes No Please list any additional notes or concerns: How did you hear about our preschool? PERMISSIONS AND AGREEMENTS I authorize the preschool staff to seek medical attention for my child in case of an emergency. * Yes, I authorize. No, I DO NOT authorize. I give permission for my child’s photos to be used for school purposes (newsletters, website, etc.). * Yes, I give my permission. No, I DO NOT give my permission. I agree to adhere to the preschool’s policies and payment agreements. * Yes, I agree. No, I DO NOT agree. Signature of Parent/Guardian: By typing my full name in the box below, I confirm my agreement to the above permissions. Thank you for submitting your application, a member of our team will be in touch with you soon.
