Heartland Career Center Preschool Application
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Date
Please select today's date
MM
/
DD
/
YYYY
Preferred Preschool Time
Child's First & Last Name
Your answer
Child's Age
Your answer
Child's Birth Date
MM
/
DD
/
YYYY
Street Address:
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Home Phone (if non-applicable enter N/A)
Your answer
Mother's Cell Phone (if non-applicable enter N/A)
Your answer
Text
Mother's Email (if non-applicable enter N/A)
Your answer
Father's Cell Phone (if non-applicable enter N/A)
Your answer
Father's Email (if non-applicable enter N/A)
Your answer
Text
Mother's First & Last Name (if non-applicable enter N/A)
Your answer
Father's First & Last Name (if non-applicable enter N/A)
Your answer
Mother's place of employment (if non-applicable enter N/A)
Your answer
Mother's place of employment phone number (if non-applicable enter N/A)
Please include area code
Your answer
Father's place of employment (if non-applicable enter N/A)
Your answer
Father's place of employment phone number (if non-applicable enter N/A)
Please include area code
Your answer
Sibling 1 First & Last Name
Your answer
Sibling 1 Age
Your answer
Sibling 2 First & Last Name
Your answer
Sibling 2 Age
Your answer
Sibling 3 First & Last Name
Your answer
Sibling 3 Age
Your answer
Sibling 4 First & Last Name
Your answer
Sibling 4 Age
Your answer
Whom do we contact in case of an emergency (if you cannot be reached at the above numbers?)
Contact Name (First, Last)
Your answer
Emergency Contact Relationship to child
Your answer
Emergency Contact Address
Your answer
Emergency Contact Phone Number
Please include area code
Your answer
Family Doctor Name
Physician first & last name
Your answer
Family Doctor Phone Number
Please include area code
Your answer
Medical Information
Allergies
Your answer
Special Medical Information
Any special medical information
Your answer
Special Interest
Your child's special interest
Your answer
Authorized people (please include first and last name and relationship to child along with phone number including area code)
Your child will not be released to any person not on this paper for safety and liability reasons
Your answer
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