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 on a waiting list for the 2017-2018 School Year. As seats become available students will be placed in order of screening outcomes. Any questions please call 815-547-9851.
Email address
Concern or Reason for Screening Request
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Child's First Name
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Child's Middle Name
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Child's Last Name
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Child's Sex
Child's Birth Date
MM
/
DD
/
YYYY
Child's City of Birth
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Child's State of Birth
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Mother's Name
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Mother's Maiden Name
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Father's Name
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Child Lives With
Street Address
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City
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Home Phone Number
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Alternate Phone Number
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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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