Preschool Intake Form


For program: Monday 9:00am-11:30am and Wednesday 9:00am-11:30am

Child’s Name:

First Name

Last Name 


Date of Birth:

Gender:


Father’s Name:

Mother’s Name:


Home Address: 


City: 

State:

Zip Code: 


Phone Number:

Mobile Number:

Email:


Does the child have sibling who is currently attending our school? 


Parent’s Signature:



$100 non-refundable application fee payment applied. 



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