Online Student Enrollment Application -

Enrollment Form

Date of Admission

MM

DD

YYYY

Date of Discharge

MM

DD

YYYY

Child's Full Name*

First Middle Last

Name Child Goes By*

First

Child's Date of Birth*

MM

DD

YYYY

Child's Birthplace*

City State

Child's Home Address*

Street Address Address Line 2 City State ZIP Code

Child's Home Phone*

Which school is your child currently attending?

School Phone

WVEIS #

Scheduled Days & Hours for Care:

Parent or Guardian Information

Guardian 1's Full Name*

First Last

Guardian's Phone

Okay to Text?

Yes
No

Guardian's Email Address

Guardian's Address

Street Address Address Line 2 City State ZIP Code

Occupation and Place of Employment

Work Phone

Social Security Number

Guardian 2's Full Name*

First Last

Guardian's Phone

Okay to Text?

Yes
No

Guardian's Email Address

Guardian's Address

Street Address Address Line 2 City State ZIP Code

Occupation and Place of Employment

Work Phone

Social Security Number

How did You Hear About Us?

Family Information

Brothers and/or sisters (Please indicate ages and whether they live with the child)

Please list any other persons living with the child and their relationship (if any) to child

Personal History

Is you child right or left handed

Right handed
Left Handed

Does your child participate in any other group setting or preschool program? (Please include Speech, Physical therapist, ect.):

If so, where and when:

List any and all food or drug allergies

Does child have any bowel or bladder irregularities?

Any additional information such as child's communication methods?

Health

Any chronic illness or hospitalization?;

Any disabilities?

Any regular medication? Also, side effects of medication?

A health assessment and immunization record signed by the child's licensed health provider must be provided

Eating

Food Allergies

How does child eat

Toilet Habits

Does child indicate bathroom needs

Words for urination?

Bowel movement?

Sleeping Habits

Does child take nap?

Yes
No

If yes, what hours of the day and how long?

What helps the child to go to sleep?

What time does your child go to bed in the evening and what time does your child wake-up?

Social Relationships

Other play groups

By nature , is child (mark all that apply):

Friendly
Aggressive
Shy
Withdrawn

How does child relate to stranger?

Does child play well alone:

Yes
No

Favorite toy:

Frightened by (mark all that apply):

Animals
Rowdy children
Loud noises
Darkness
Storms

Other

How do you comfort your child?

Does the family receive any support from agencies in the community?

Is the family receiving support from early intervention?

Field Trip Permission Slip and Transportation Polices

My child has permission to attend and to be transported by Playmates Preschool and Child Development Centers, Inc. paid employees and volunteer staff to field trips. Type child name in the box below.

Parents please discuss with your child or children the importance of field trip rules.

* Seat Belts (children and adults.
*No standing or yelling on vans (children and adults)
*No eating or drinking on vans (May cause choking) (children and adults)
*Always use our best manners on van and places we visit ( children and adults)
*For many years we have had a reputation for having very well-behaved children when we visit places.
We at Playmates feel that with our staff and parents working together, we will continue to have safe, fun, and wonderful trips. Thank you for being an involved parent.