Toddler Application
Ages 12 - 36 months


Email address *
Schedule Preferences
Anticipated Date of Enrollment *
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How many days would you like your child to attend? *
What is your first schedule preference? *
Required
What is your second schedule preference? *
Required
Contact Information
Child's First Name *
Your answer
Child's Middle Name *
Your answer
Child's Last Name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Gender *
1st Parent's Name *
Your answer
1st Parent's Email Address *
Your answer
1st Parent's Primary Phone Number *
Your answer
1st Parent's Street Address *
Your answer
1st Parent's City *
Your answer
1st Parent's State *
Your answer
1st Parent's Zip Code *
Your answer
1st Parent's Employer
Your answer
1st Parent's Work Address
Your answer
1st Parent's Work Phone
Your answer
2nd Parent's Name
Your answer
2nd Parent's Email Address
Your answer
2nd Parent's Primary Phone Number
Your answer
2nd Parent's Street Address
Your answer
2nd Parent's City
Your answer
2nd Parent's State
Your answer
2nd Parent's Zip
Your answer
2nd Parent's Employer
Your answer
2nd Parent's Work Address
Your answer
2nd Parent's Work Phone Number
Your answer
Siblings - Please list siblings name, date of birth, and gender
Your answer
Family Questionnaire
Please describe the pregnancy and birth ( i.e. c-section, complications during pregnancy and birth, adoption, etc). *
Your answer
Please describe your child’s daily rhythm from the time they wake up until they go to bed. *
Your answer
Has your child been in regular out-of-home care before (include where and length of time)? *
Your answer
Has your child had a regular in-home caretaker who is not a parent? If so, who was the caretaker? *
Your answer
What types of family activities do you enjoy together? *
Your answer
Please describe your child’s personality (including strengths and areas you’d like to see strengthened). *
Your answer
Please describe how your child plays with other children. *
Your answer
Please describe how your child plays alone. *
Your answer
Does your child watch T.V., movies, or videos or play computer/tablet games? How often? Do you watch/play with them? *
Your answer
Are you willing to decrease the amount of your child’s screen time if your teacher feels it would benefit your child? Please answer as fully as you are able. *
Your answer
What types of food does your child like to eat? *
Your answer
Develomental Milestones
Please let us know at what age your child accomplished the following milestones.
Crawl *
Your answer
Sit Up *
Your answer
Walk *
Your answer
Grow first tooth *
Your answer
Speak first word *
Your answer
Medical History
What illnesses has your child had, particularly including measles, mumps, diphtheria, rubella, shigella, hepatitis (type?), meningitis (type?), salmonella, chicken pox, or giardia? *
Your answer
Does your child have any allergies or health issues? *
Your answer
Other
Have you attended a BWK Parent Tour? *
If you have attended a tour, what was the date?
Your answer
How did you hear about this program? If you found us on the web, which websites and search engines, and what words did you search on? *
Your answer
Anything else you would like to add?
Your answer
A copy of your responses will be emailed to the address you provided.
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