The Learning Center Interest Form
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Child's Last Name *
Child's First Name *
Child's Date of Birth (month/day/year)  *
Child's age as of September, 2025 *
Future School
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Parent/Guardian Information
Parent/Guardian # 1 Last Name *
Parent/Guardian # 1 First Name *
Parent/Guardian # 1 Street Address *
Parent/Guardian # 1 City *
Parent/Guardian # 1 Zip Code *
Parent/Guardian # 1 Home Phone *
Parent/Guardian # 1 Cell Phone *
Parent/Guardian # 1 E-Mail Address *
Parent/Guardian # 2 Last Name *
Parent/Guardian # 2 First Name *
Parent/Guardian # 2 Street Address *
Parent/Guardian # 2 City *
Parent/Guardian # 2 State *
Parent/Guardian # 2 Zip Code *
Parent/Guardian # 2 Home Phone *
Parent/Guardian # 2 Cell Phone *
Parent/Guardian # 2 E-Mail Address *
Names, Gender, and Ages of Siblings of Child
What is the primary language spoken at home? *
I understand that I will need to submit an updated medical form before the first day of attendance.  *
List any experiences your child has outside of the home with other groups of children that meet on a regular basis (e.g. weekly playgroups, recreation department programs, church nursery, etc.) *
Does your child have any allergies?   *
List any medical conditions (e.g. asthma, respiratory conditions, etc)   *
Does your child have any disabilities?   *
If your child has a disability, is there a specific way a situation should be handled?
List your child's favorite activites *
Describe your child's personality *
Is there any information that we should be aware of which will ease your child's adjustment to preschool? *
Is there anything else we need to know about your child?
At the preschool, we like to take photos of the children for both educational purposes to show future students examples of certain types of learning as well as for our newsletter, twitter, and our end-of-year slideshow. All photos are taken following Board of Education policy (at least 3 people in a photo). Please let us know your decision about photos: *
Do you have any additional questions? *
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