Information of Child
First Name: Last Name:
Nickname: Gender:
Date of Birth:  (mm/dd/yyyy) Age on September 1:
Primary language spoken at home: 
  Information of Parent(s) or Guardian(s) with Whom Child Lives
#1   First Name: Last Name:
City/Town:  State: Zip:
Phone:  Cell Phone:
#2   First Name:  Last Name: 
City/Town:  State: Zip:
Phone: Cell Phone:
  Additional Information of Child
 Has you child had any group experiences with other young children?

 Is your child currently participating in a play group or enrolled in an early
 childhood program?

 When would you like your child to start in the preschool?

 Do you have any questions/comments?

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