Preschool Application Form
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1
213
625 EDS Driv
e
Hern
don, VA 2017
1
(
(703) 713-3332
2
(703)
713-3336 FAX
X
ww
m
P
Preschool A
Applicatio
on Form
Stude
ent Legal Nam
me:
________
_______
Last
F
First
Middle I.
(Nickname)
Date of Birth
th
______
_______________
_______________
________________
____________
______________
________________
______
_______
___ __________
_________
Street A
Address
City
State
Zip Code
______
_______________
_______________
________________
____________
______________
________________
______
_______
___ __________
_________
Second
d Address if applic
cable
City
State
Zip Code
Gende
er: Male ____
_
Begin
nners - 3 yr. olds
(Arrival from 8
am-8:25) 8:30-2
2:30 M-F School
l Year to Start __
______________
____
Female ____
__
Pre-K
Kindergarten - 4 y
yr. old (Arrival f
from 8am-8:25)
8:30-2:30 M-F:
School Year to
start _________
_________
Addi
itional Service
es:
Bus Trans
sportation: Mor
rning _____
Exten
nded Care Needs
s: Morning (7am
m Start) _____
Afte
ernoon _____
Afternoon (2:3
30-6pm) _____
Moth
her’s Name: __
____________
_____________
____________
__
____
_____________
________
__________
___________
Home
e Phone
Cell Phone
______
_______________
_______________
________________
_______________
__
____________
______________
Place o
of employment
Occup
pation
Business Phon
ne
Email-
-1: _____________
_______________
_______________
_______________
Email-2: _____
_______________
_______________
________________
______________
Fathe
er’s Name: __
_____________
____________
____________
____
_____________
_______
__________
____________
_
Home
e Phone
Cell Phone
______
_______________
_______________
________________
_______________
__
___
________
Place o
of employment
Occup
pation
Business Phon
ne
_________
__________
___________
__________
_
___
___________
__________
___________
__________
_
Email-
-1:
Email-2:
Stude
ent Lives With
h: Mother___
_ Father____ B
Both____ Guar
rdian____ Othe
er: __________
____________
____________
_____________
_
List O
Other Childre
en in Family a
and Birth Date
es:__________
____________
_____________
____________
_____________
____________
_
_____
____________
_____________
____________
_____________
____________
____________
_____________
____________
_____________
_
Curr
rent School / D
Daycare: _____
____________
_____________
____________
____________
_____________
____________
_____________
_
List A
All Previous C
Childcare and
Schools Atten
nded Since Bir
rth
(if none atten
nded, please indica
ate not applicable N
N/A):
_____
____________
_____________
____________
_____________
____________
____________
_____________
____________
____________
_____
____________
_____________
____________
_____________
____________
____________
_____________
____________
____________
_____
____________
_____________
____________
_____________
__________
_______
____________
_____________
_
Pleas
se remember t
to enclose you
r non-refunda
able $250 App
plication Fee _
_____
I cert
tify that all the
e above inform
mation on this s
student’s appli
ication form is
s true and corr
rect to the best
t of my knowle
edge.
_____
______________
______________
_____________
______
_____________
_____________
______________
______
Paren
nt Name (Print/
/Type)
Parent Signat
ture
Da
ate
====
===========
===========
====== For O
Office Use Onl
ly: Please do n
not write below
w this line ===
===========
===========
=
___________
______
Application Fee
e
Check Number
D
Date Received
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