Goochland County Preschool Application
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Email *
2022-2023 School Year
Children must be 3- or 4- years old by September 30, 2022.  Application does not guarantee enrollment in the programs.  All information provided is confidential and is used to determine eligibility.
Child's Name *
Elementary school district where your child resides:
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Child's Gender
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Child's Birth Date *
MM
/
DD
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YYYY
Language Spoken in Home
Name of Parent/Guardian # 1 *
Address of Parent/Guardian # 1 (Street Name, City/County, Zip Code)
Phone Number of Parent/Guardian# 1 *
Email Address of Parent/Guardian # 1
Parent/Guardian # 1's Occupation *
Educational Level of Parent/Guardian # 1 *
Name of Parent/Guardian # 2
Address of Parent/Guardian # 2 (Street Name, City/County, Zip Code)
Phone Number of Parent/Guardian # 2
Email Address of Parent/Guardian # 2
Parent/Guardian #2's Occupation *
Educational Level of Parent/Guardian # 2 *
If the child lives with someone other than his/her parents, please describe the living situation below.
Total number of people living in the child's household
Please list all other members of the household (including siblings, spouses, and other children).  Please list their names, ages, and relationships to the child.
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