Preschool Registration Form printable pdf download

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

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

Mother/ Guardian Mailing Address

Father/ Guardian Mailing Address

(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.

Hispanic

Non-Hispanic

Black, African American

Email Address:

White

Asia

Pacific Islander/Hawaiian

American Indian, Alaska Native

Native Language of Student:

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

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

Preschool Registration Form

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