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APPLICATION FOR ADMISSION

Child’s First Name _____________________________ Last Name____________________________________


Date of Birth __________________________________ Male _____ Female _____
Home Address ________________________________ City _______________ State_______ Zip___________
Home Phone__________________________________ Date of Application _____________________________

Parent/Guardian Parent/Guardian

Name _______________________________________ Name _______________________________________


Address (if different) _____________________________________ Address (if different) _____________________________
City________________ State ______ Zip ___________ City ______________ State_______ Zip ___________
Phone (if different) _______________________________ Phone (if different) _______________________________
Cell Phone ___________________________________ Cell Phone ___________________________________
Occupation ___________________________________ Occupation ___________________________________
Employer_____________________________________ Employer ____________________________________
Bus. Telephone _______________________________ Bus. Telephone _______________________________
Email________________________________________ Email _______________________________________

Please consider my child for the following grade level:

Twos Threes Fours Afternoon Explorations


Please rank your program Please rank your Note - All 4’s attend Morning 3’s and 4’s may add a special
preferences. preferences. preschool M - F. class on any day (M-Th). Each day will
have a different theme (cooking, art,
2 Mornings* 3 Mornings* 5 Mornings* drama, etc.).

T & Th M, W, F Monday - Friday Please let us know which afternoons you


9:00 AM – 11:30 AM 9:00 AM- 12:30 PM 9:00 AM - 12:30 PM wish to add:

3 Mornings*
T, Th, F

M, W, Fri
9:00 AM- 12:30 PM
Mondays 12:30pm - 2:30 PM

9:00 AM – 11:30 AM 5 Mornings*


M-F Tuesdays 12:30pm - 2:30 PM
5 Mornings* 9:00 AM- 12:30 PM
M–F Wednesdays 12:30pm - 2:30 PM
9:00 AM – 11:30 AM 4 Afternoons**
M - Th
Thursdays 12:30pm - 2:30 PM
12:30 PM – 3:00 PM

*Early drop-off available 8:30 daily


**Late pick-up available daily until 3:30
Has your child attended a preschool before? _____________________________________

Name of school_____________________________________________________________

What is the primary language spoken at home? ___________________________________

What other languages are spoken at home? ______________________________________

Please give names and dates of attendance of relatives who are/were students at Union Temple
Preschool __________________________________________________________
_________________________________________________________________________

Has your child previously applied to Union Temple Preschool? _______________________


When? ___________________________________________________________________

Has your child received any educational support services? Please specify (e.g. - speech,
play therapy, OT, PT, SEIT) ___________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Do you have any areas of concern regarding your child (e.g. - physical, cognitive, social)?
_________________________________________________________________________
_________________________________________________________________________

Does your child have any health issues of which we should be aware? _________________
_________________________________________________________________________

Are you a member of Union Temple? ___________________________________________

Would you be interested in getting information about joining Union Temple? ____________

Parent’s Signature __________________________________________________________

Please return this application along with a $60 non-refundable application fee payable to
Union Temple Preschool. We accept checks only, no cash please.