Enrollment Application

All fields marked with a * are required and must be filled in.
*Informant Name: Relation to Child:
Referral Source:
If referral source is "other":

Child
*Last Name: *Address:
*First Name: *City:
Middle Init: *Zip:
*Gender: *Date of Birth:

Mother

*(note: name, home phone, and relation information must be entered for at least one parent)
Last Name: Home Phone:
First Name: Work Phone:
Middle Init: Relation to Child:
If relation is "other":

Father

*(note: name, home phone, and relation information must be entered for at least one parent)
Last Name: Home Phone:
First Name: Work Phone:
Middle Init: Relation to Child:
If relation is "other":

Siblings
List the names of the siblings of the child entered above.
Name of Sibling 1: Date of Birth:
Name of Sibling 2: Date of Birth:
Name of Sibling 3: Date of Birth:
Name of Sibling 4: Date of Birth:

Program Related Questions
Does your child currently attend preschool? Yes No
Does your child currently attend kindergarten? Yes No
Please enter the preschool or kindergarten school name:
Is this a Headstart Program? Yes No
What language is primarily used at home?
Would you feel comfortable attending a group conducted in English? Yes No
Do you have reliable transportation to get to the groups each week? Yes No
Would you be willing to participate in carpooling with other parents in the group? Yes No
Do you currently have health insurance for your child? Yes No
If yes, what is the name of the provider?
If no, would you like help obtaining insurance? Yes No
Is your child potty trained? Yes No
Does your child have any food or medication allergies? Yes No
If yes, list allergies below:
Does your child have any diagnosed medical or psychological conditions? Yes No
If yes, list conditions below:
*How many parents (i.e. adults) will attend the groups?
*Are you planning to bring your (one) 3-5 year old to sessions 1 through 10 for child care? Yes No
Comments:
For Staff Use Only:
All fields marked with a * are required and must be filled in.


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