Preschool Intake Form
Thank you for your interest in the Canal Winchester Preschool Program. Please complete this form and click the submit button at the bottom to apply for our program.  
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Email *
Child's First Name *
Child's Last Name *
Child is a: *
Child's Date of Birth (mm/dd/yyyy) *
*To be a Peer Model, your child MUST be at least 4 years old and toilet trained.
MM
/
DD
/
YYYY
Is your child fully potty trained? *
Street Address *
You and your child must reside within the Canal Winchester Local School District. Please provide your address.
City *
State *
Zip code *
Your Name *
Which of the following has your child attended: *
Required
If you selected a program from the above question, please provide the name of the program, dates the child attended, and the frequency of your child's attendance.
Your Phone Number *
Your Email Address *
What is your relationship to the child? *
Do you have legal custody of the child? *
Describe your child's strengths. *
Do you have concerns about your child's development? *
What language did your child learn first? *
What language does your child use most at home? *
What languages are used in your home? *
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