Wanaque Public Schools
Preschool Registration Form
(Please Print or Type)
I am registering for the 3 year old
I am registering for the 4 year old
AM class 9:00-11:30
PM class 12:30-3:00
Must be 3 years old by October 1, 2016
Must be 4 years old by October 1, 2016
Enroll Date: / /
School:
Student ID #:
Office use only
Students Last Name:
First Name:
Middle:
Date of Birth: / /
Age:
Toilet Trained
Gender: Female
Male
Must be the proper age by 10/01/20016
Yes
No
Parent (s) / Guardian Names:
Person Enrolling Student:
Relationship if other than parent:
Student’s Physical Address:
Mother / Guardian Physical Address:
Father / Guardian Physical Address:
Same as Student’s Physical Address
Same as Student’s Physical Address
Mother/ Guardian Mailing Address
Father/ Guardian Mailing Address
(Only if Different):
(Only if Different):
Mailing Address (Only if Different):
Mother/Guardian Home #
Student’s Home Telephone #
Father/ Guardian Home #
Mother/ Guardian Cell #
Father/ Guardian Cell #
Ethnicity:
Mother/ Guardian Work #
Father/ Guardian Work #
Response’s Optional
Ext.
Ext.
Hispanic
Non-Hispanic
Black, African American
Email Address:
Email Address:
White
Asia
Pacific Islander/Hawaiian
American Indian, Alaska Native
Native Language of Student:
Check here If English is spoken &
Check here If English is spoken &
understood by student
understood by parent/ guardian
Student’s Prior School’s Name:
Prior School’s City/Town, State:
Please list:
Special Program Needs
(Special education, English as a Second Language (ESL), Basic Skills, Speech/ language delays
Please describe:
Please list other special considerations (e.g., custody, medical, etc.):
Siblings in Household (full name) :
Age:
Grade:
I understand I must provide transportation to and from the program for my child.
I agree to pay a deposit of $200.00 with this application to secure an available opportunity followed by
th
th
nine (9) monthly payments of $200.00 which are due by the 15
of every month beginning July 15
.
If my child is not chosen in the lottery, I understand my deposit will refunded.
___________________________________________
__________________________
Parent/ Guardian Signature
Date
Please fill out back of form
2015