Belvidere Preschool Screening Request
Please fill out form. Screenings are held once a month. You will be contacted by our office when a screening date is available. We are currently screening for the 2018-2019 School Year. As seats become available students will be placed in order of screening outcomes. Any questions please call 815-544-9851.
Email address *
Concern or Reason for Screening Request *
Your answer
Child's First Name *
Your answer
Child's Middle Name *
Your answer
Child's Last Name *
Your answer
Child's Sex *
Child's Birth Date *
MM
/
DD
/
YYYY
Child's City of Birth *
Your answer
Child's State of Birth *
Your answer
Mother's Name *
Your answer
Mother's Maiden Name *
Your answer
Father's Name *
Your answer
Child Lives With *
Street Address *
Your answer
City *
Your answer
Home Phone Number *
Your answer
Alternate Phone Number *
Your answer
Child's Language *
Required
Child's Ethnicity *
Has the Child Been Screened Before? *
Has the Child Attended a Preschool Program? *
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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