Toddler Application for Admission

Student Name:  

Date of Birth:

Gender

Age of student on start date: Years   Months

Student Address:

Street

City State Zip code

Primary Doctor: Phone #

Disabilities or limitations?

If yes please explain:

Medical concerns:

(ADD/ADHD, asthma, allergies, diabetes, etc):

If yes, please explain

Parent Information

Mother/Guardian Name:

Street

City State Zip code

Mother Email:

Phone #:

Occupation: 

Work #: 

Language spoken at home:  

Father/Guardian's Name:

Street

City State Zip code

Father Email:

Phone #:

Occupation: 

Work #: 

Language spoken at home:  

Additional Information

Name and age of siblings:

Brother(s):

Sister(s):

About Your Child:

Has your child been cared for by anyone other than parents? 

Has your child previously attended a day care center? 

Does your child use the restroom independently? 

Does your child need help dressing or undressing? 

Does your child take a nap?

Does your child have any fears?

Favorite games: 

Favorite toys:

Favorite books:

Favorite TV shows:

Favorite outdoor activities: 


Parent Digital Signature 

Today's Date: