The Village Preschool and Early Education Centers

Infant-Toddler-Preschool Application

Please Select 160 Cave Rd. 115 Centre St. 2123 Dover Rd.

A Location: ____Clarksville, TN 37043 ____Pleasant View, TN 37146 ____Woodlawn, TN 37191

Date of Admission___/___/___ Date of Birth___/___/___

Full Name of Child________________________What does your child like to be called? (NO NICKNAMES) PLEASE)

Parents: Cell Phone:_________________

Mother’s Name____________________ Employer:_____________________

Address:_________________________ Work Phone_____________________

City, State, Zip____________________ Ext.Number_______Hours_________

Home Phone _____________________ SSN#_________________________

E-Mail Address:_____________________________

Cell Phone:_________________

Father’s Name:____________________ Employer_______________________

Address:_________________________ Work Phone:____________________

City, State, Zip_____________________ Ext.Number_______Hours__________

Home Phone______________________ SSN #__________________________

E-Mail Address:_____________________________

Transportation Plan:

To insure the safety of your child, please list other adults to whom we may release your child. Please remember these individuals must show a valid I.D. an be at least 18 years of age. You must notify the center in advance if someone else is picking up your child.

Name Social Security Number

1._________________________________ __________________________________

2._________________________________ __________________________________

3._________________________________ __________________________________

4._________________________________ __________________________________

5._________________________________ __________________________________

We must have your written permission or proper notification by phone before reeasing your child to anyone.

Emergency Information:

Name of person, other than the center director, authorized to act for parent in case of emergency.

1. Name:________________________Home Phone:________________________

Address:________________________Work Phone:_________________________

Employer:_______________________Work Hours:_________________________

Cell Phone:______________________

2.Name of Physician:_______________Office Phone:________________________

Chart#_________________________ Office Address:_______________________

Background Information:

Other Chilren in Family: Birthday School

1.____________________ ___/___/___ _____________________

2.____________________ ___/___/___ _____________________

3.____________________ ___/___/___ _____________________

Experiences with others:

What are some of the ways in which your child at home?_______________________

_________________________________________________________________

Does he/she play with children from other families?______How?_________________

_________________________________________________________________

Does he/she usualy get his/her way withother children?______If not how does he /she react?_____________________________________________________________

Is the entire family together during the day?_________________________________

Allergies:___________________________________________________________

Eating Habits:

At what time does the child eat breakfast?_______lunch?________supper?________

Between meal snacks?__________Does he/she feed his/herself?________________

What is his/her general attitude toward eating?______________________________

If he/she refuses to eat,how is this handled and by whom?_____________________

________________________________________________________________

Favorite Foods:_____________________________________________________

Disliked Foods:_____________________________________________________

Food Allergies!_____________________________________________________

Sleep Habits:

Has room alone?_______Shares room with other children?_______Shares room with parents?______Sleeps at night from:______to________.Average hours__________

Naps from________to________Average hours_______.How is your child’s attitude toward going to bed?_________________________________________________

Does he/she wet the bed?_______At Nap?___________At Night?______________

Habits associated with going to bed?_____________________________________

________________________________________________________________

Tollet Habits:

Times at which your child is taken to the bathroom:_____________________ Does he/she take his/herself?_____Time of bowel movement ? _____Easily constipated?_____ Does he/she manage his /her clothes at the toilet?______________

What word does he/she use for urination?________Bowel movement ?__________

Speech and Physical Growth:

How does your child speak ? Well_____Fairly Well_______Not Very Well_______Not at All____

Does anyone read to your child?_______How regularly? ______________________

At what age did your child creep________crawl_______walk________? Would you describe your child as average_____short_____tall_____? Friendly_____Unfriendly_______

Additional Comments:

If there is any additional information that is critical to your child’s well being while in the care of the center, please attach an additional sheet of information.

Signature Sheet

I have received a summary of licensing requiements. I do here by authorize The Village Preschool and EEC to request emergency care for my child.

Weeky Fee:_________Enrollment Status:__________________________________

Date Of ENR. ___/___/___

___________________________________ __________________

Mother’s Signature Date

___________________________________ ___________________

Father’s Signature Date

____________________________________ __________________

Director’s Signature Date