2022-2023 Returning Student Application
This Enrollment Application is only for Students who were enrolled in the Preschool Program at Vivian D. Adams Early Childhood Center or Dr. Katie Harper Wright during the 2021-2022 academic year. Note: Additional Documents* may be required to complete the Returning Student Enrollment process - including Birth Certificate, Proof of Residency, Proof of Income, Updated Medical Records, etc.

Information contained on this form will be kept CONFIDENTIAL. Knowing information regarding your child / family will assist our staff in determining eligibility and priorities for program placement. Please check the box below to confirm that acknowledge this statement:
Sign in to Google to save your progress. Learn more
Yes, I acknowledge this statement: *
Required
Date: *
MM
/
DD
/
YYYY
Child's Full Name (as listed on Birth Certificate): *
In which school was your child previously enrolled? *
Required
Teacher's Name / Classroom (from previous school year): *
Name of Person completing this application: *
Relationship to child: *
Required
What is your current ADDRESS (including city and zip code)? *
What is your current TELEPHONE NUMBER? *
What is your current EMAIL ADDRESS? *
MEDIA RELEASE
Students in School District 189 may be included in photographs, videotaped or recorded interviews, and the information collected by the media to be used as part of news stories to be published in print, internet, broadcast or video by the school, news media or School District 189. Images and/or filmed or audio recordings will not be used for commercial gain and will not be sold to anyone for commercial use. If you DO NOT give School District 189 permission for your child to be photographed or filmed, please complete the statement below.
As the parent / guardian of the above-named student at the above-selected school, I DO NOT give permission to School District 189 to photograph or videotape my child. (If you DO NOT give permission, enter your Name and the Date below.)
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of East St. Louis School District 189. Report Abuse
Google Forms