The Village Preschool and Early
Educations Centers School Age Child's
Application
Please
Pick 160 Cave Rd. 115 Centre St. 2123
Dover Rd.
A
Location: ____ Clarksville, TN
37043 ____ Pleasant View, TN
37146 ____Woodlawn, TN
37191
Elementary
school ________________________ Grade
on admission date____________
Date of
Admission____/____/______Child's Full Name___________________________
What does
child like to be called?_________________ Child's Birth Date___/___/_______
(No
Nicknames Please)
Parent
Information:
Cell Phone:____________________
Mother's
Name:_____________________________ Home Phone:____________________
Home
Address:____________________________________________________________________
street
Apt. #
City State Zip Code
Where
Employed:__________________________ Work Phone:________________________
E-Mail
Address_____________________________
Cell Phone:____________________
Father's
Name:_____________________________ Home Phone:____________________
Home
Address:____________________________________________________________________
street
Apt. #
City State Zip Code
Where
Employed:__________________________ Work Phone:________________________
E-Mail
Address_____________________________
If parents
are divorced, which parent has custody of Child?____________________________
For the
Child's safety, list other persons to whom the child may be released. Please include the social security number of
these people so that we may enter them in the computer system so that they may
have access to pick up your child.
Name Social Security Number
________________________________
___________________________________
________________________________
___________________________________
________________________________ ___________________________________
________________________________
___________________________________
________________________________
___________________________________
________________________________ ___________________________________
Emergency
Information:
Name of
person in the Clarksville area, other than someone at center, who is authorized
to act for the parent in case of an emergency.
Cell Phone:__________________________
Name:_______________________________ Home Phone:__________________________
Where
Employed_______________________ Work
Phone:__________________________
Name of
Child's Physician__________________
Office Phone:________________________
Office
Address:_______________________________________________________________
Background
Information:
Other
children and adults in the home
Age School child attends:
_______________________________ ____
_______________________________
_______________________________ ____ _______________________________
_______________________________ ____ _______________________________
_______________________________ ____ _______________________________
_______________________________ ____ _______________________________
I
hereby authorize the center to provide emergency medical care. I have received a summary of licensing
requirements.________________________
______________________________________________________________
Allergies:
Food
Allergies:_____________________________________________________________
Insect
stings, Bites:_________________________________________________________
Medications:_______________________________________________________________
Experiences
with others:
Describe
your child's adjustment to school:______________________________________
_________________________________________________________________________
_________________________________________________________________________
List your
child's hobbies and interests:__________________________________________
_________________________________________________________________________
What are
some ways in which your child plays at home?___________________________
________________________________________________________________________
Does your
child play with neighborhood children? _____If so, how___________________
_________________________________________________________________________
Does your
child usually get his/her way with other children_____ If not, how does he/she
react?_______________________________________
Is the
entire family together during the day?______ Has
your child had the following experiences in the past year? Birth of another
child in the family?_______ Moving?______
Changing
Schools?_____ Serious illness of child or family member?____ Death in family?
____ Separation or divorce of parent?_____
Other:_______________________________
Would you
describe your child as: _____active ______quiet _____friendly _____shy?
What do
you like best about your child?________________________________________
________________________________________________________________________
Is there
any other information we need to know about your child?___________________
________________________________________________________________________
________________________________________________________________________
I hereby
affirm that my child's immunization and Health Record is on file at
____________
________________Elementary
school.
___________________________________
______________________
Parent
Signature
Date
___________________________________
______________________
Director's
Signature
Date