Pickerington Preschool 19-20 Application
Thank you for your interest in Pickerington's Early Childhood Program. Please complete this form and click the submit button at the bottom to apply for the 2019-2020 school year. If you have any questions, please contact Sherri Dittoe at 614-920-6162 or Tammy Pruden at 614-920-6163.
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Estimated tuition fee is 154.00 per month
For students who do not qualify as having a disability, you will be charged a tuition fee of 10.00 a day with an estimated charge of 154.00 per month.
Child's First Name *
Your answer
Child's Middle Name *
Your answer
Child's Last Name *
Your answer
Nickname *
Your answer
Child is: *
Child's Date of Birth *
Note: Your child must be approximately 3 years old to attend
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Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Parent/Guardian's Name 1 *
Your answer
Parent/Guardian's Name 2
Your answer
Home Phone Number
(with area code)
Your answer
Mom's Cell Phone Number
(with area code)
Your answer
Mom's Email Address
Your answer
Dad's Cell Phone Number
(with area code)
Your answer
Dad's Email Address
Your answer
Do you suspect any problems with your child's development? *
If yes, please list your concerns.
Your answer
Please complete the section below by marking yes or no.
*
yes
no
Eats and drinks independently
Dresses self except for shoes
Independent with toileting needs (may need help with difficult snaps or buttons)
Verbally interacts with peers in a play situation
Makes basic needs known
Responds to simple questions
Follows simple directions
Speaks in sentences
Independently picks up small toys
Uses toys and objects appropriately
Uses imagination to play
Will share toys and cooperate in play
Takes turns with minimal assistance
Shows understanding of how things work by turning things on/off, activating a variety of toys, or directing adults to do so
Other preschool experiences your child has had:
Your answer
How well does your child separate from parents? *
Your answer
List Languages your child can speak fluently and understandably:
Your answer
Would you like an interpreter present at your child's scheduled screening?
If yes, what language?
Your answer
Please describe your child's strengths: *
Your answer
Please describe what is difficult or challenging for your child: *
Your answer
What are your child's interest:
Your answer
Please describe how well your child interacts with other children his/her age: *
Your answer
Why would you like for your child to be enrolled at Pickerington Local Preschool? *
Your answer
Please select your preference for preschool. *
select am or pm
Are there any custody concerns? *
Please select one of the options below.
Kindergarten start date *
Please indicate the year you anticipate that your child will start kindergarten. Please be aware that children must be age 5 by August 1st in order to start kindergarten.
The Sections below are required for all applicants but will only apply for Peer Models.
If you have any questions, please contact Tammy Pruden at 614-920-6135 or Sherri Dittoe at 614-920-6164.
If my child is accepted as a peer model, I agree to pay the established tuition of 10.00 per day or an estimated tuition of 153.33 for 9 payments due on the 15th of each month.   *
(My student will attend 4 days a week for 2.75 hours a day, Monday - Thursday)
If my child is accepted as a peer model, I understand I am required to provide transportation for my child to and from school. *
Required
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