I Am Interested in The Following Program
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Full Name of Child
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
School District (and Elementary School)
Parent/Guardian Name #1
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First Name
Last Name
Relationship to Child
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Parent /Guardian Phone Number
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(###)
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Parent/Guardian Email
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Parent/Guardian Name #2
First Name
Last Name
Relationship to Child
Parent/Guardian Phone Number
(###)
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Parent/Guardian Email
Status of Parents/Guardians
Name of Siblings
Others in Your Household
My Child's Strengths Are
My Child Needs to Improve
Have there been any recent births, deaths, adoptions or changes in your child's family structure that may affect your child? If so briefly describe the situation and the effect on your child.
What opportunities does your child have to play with other children? (check all that apply)
List your child's favorite play activities
What fears does your child have and how are they expressed?
Does your child have any security items? If so, what is it and what are the guidelines about using it?
Additional Information you feel would be useful
Emergency Contact Information #1
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List below the names of TWO people we can contact if a parent/guardian cannot be reached. Also, please indicate by checking YES/NO if this person is authorized to pick up your child from preschool.
First Name
Last Name
Relationship to Child
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Emergency Contact Phone Number
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(###)
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Authorized to Pick Up Child
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Emergency Contact Information #2
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First Name
Last Name
Relationship to Child
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Emergency Contact Phone Number
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(###)
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Authorized to Pick Up Child
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Does your child currently have any health conditions? If yes, please list.
Is your child currently on any medications? If yes, please list.
Does your child have any allergies? If so, please list
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What symptoms are present during an allergic reaction? (hives, red skin, swelling, etc.)
What should be done if your child has an allergic reaction? (Epi-pen, wash, etc.)
Does your child have any dietary restriction?
Have you, or your doctor, noticed any delays in your child's development that we should be aware of?
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If Yes, Please Explain
In case of accident or serious illness, I request that Hope Preschool contact me or an emergency contact listed above. If Hope Preschool is unable to reach me or an emergency contact, I hereby authorize Hope Preschool to call the physician or dentist below and to follow their instructions. If impossible to contact this physician, Hope Preschool may make whatever arrangements they deem necessary to ensure the safety of my child.
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Physician Name
First Name
Last Name
Physician Number
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(###)
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Dentist Name
First Name
Last Name
Dentist Number
(###)
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Additional Notes
I give permission for my child to accompany the class outdoors to play on the church grounds, the school playground, and to go on short walks on the Rail Trail.
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Public Photo Release
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Private Photo Release
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Payment/Tuition Information
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Applications are processed upon receipt of the $50 non-refundable registration fee, plus one-half of the first month's tuition. Your child's spot is not reserved, until we receive your application AND non-refundable registration fee AND one-half of the first month's tuition. Payments online, or dropped off to Hope Preschool in the form of cash or check, are acceptable.
Applications are processed as they are received. Hope preschool will notify you immediately, if your preferred session is full. In the event your child's preferred program is not available, we will make every attempt to accommodate your child in a different session. If we are unable to accommodate your child, your tuition deposit will be refunded.
Signature
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By typing my name here it signifies that I have read and understood everything contained in the Hope Preschool application, including the Emergency Contact Information and Photo Release Content. I understand that if I want anyone besides a parent or guardian, or a person listed as an emergency contact, to pick up my child that I must submit a signed letter to keep in their file.
First Name
Last Name
How did you hear about Hope Preschool?
Is your family a member of a church? Which one?
