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         MI CASITA APPLICATION FOR ADMISSION                                        

APPLICANT                                                                                 DATE__________________

CHILD’S NAME ______________________   _______________________     ______________________

                                                      (first)                         (middle)                                    (last)

NAME CHILD IS CALLED BY _________________________  DATE OF BIRTH __________________  

GENDER:    F       M       X

Siblings

Name ___________________________________    Age____________________  Twin?     YES      NO

Name ____________________________________  Age ____________________  Twin?    

FAMILY: 

(1) PARENT/ GUARDIAN NAME ________________________________________________

Address ______________________________________________________          ____________

                                                 (number and street)                                                                                   (apartment number)

__________________      ________                 _________________

                  (city)                                    (state)                                         (zip code)

Telephone:____________________________________E-mail:________________________________

(2) PARENT/GUARDIAN NAME  ________________________________________________

Address (if different from child’s)    _______________________________________________________          

                                                                               (number and street)                                                                             (apartment number)

__________________      ________                 _________________

                  (city)                                    (state)                                         (zip code)

Telephone:___________________________  E-mail:_______________________________

CHILD’S LANGUAGE EXPERIENCE- please fill in the language(s) spoken at home with your childs

FAMILY/CAREGIVER

PARENT/GUARDIAN 1

PARENT/GUARDIAN 2

NANNY/LIVE IN FAMILY

LANGUAGE

CHILD RESPONDS IN...

CHILDCARE, SCHOOL OR GROUP EXPERIENCE:

 

DOES YOUR CHILD HAVE A NANNY?  YES _______   NO _______  IF YES, HOW LONG? FT _____  PT ___

HAS YOUR CHILD ATTENDED SCHOOL/PROGRAM/PLAYGROUP?    YES _________   NO _________

IF YES

NAME OF PROGRAM

NUMBER OF HOURS PER DAY

NUMBER OF DAYS PER WEEK

1.

2.

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Please answer the following:

Why did you choose Mi Casita Bilingual Preschool and Cultural Center for your child?

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Signature: _________________________________________________ Date: __________________

Please send the application to Mi Casita with $50 check or money order to our temporary address:

Mi Casita Admission

c/o Eva Ruiz

634 Hancock Street

Brooklyn, NY 11233

Gracias!

INTERNAL USE:

FEE RECEIVED DATE                         RECEIVED                                         TOUR DATE