Peer Application for Center School Preschool 2012-2013

                                                                                                                                                            Return by May 4, 2012                          
                                                                                                                                                                                                      
                              WILLINGTON CENTER SCHOOL PRESCHOOL  PEER APPLICATION (CONFIDENTIAL)

 
Child’s Name ____________________________________________________ Sex:  M (  )  F (  )

                        (last)         (first)      (middle)

 

Age  ______________________            Date of Birth ________________

 

Parent/Guardian ______________________________________________________________________

 

Address _____________________________________________________________________________

 

Telephone _______________________Home        ___________________Work

 

Siblings_______________________ D.O.B. ______            ___________________________ D.O.B _____

 

            _______________________ D.O.B. ______            ___________________________ D.O.B. _____

 

Child’s Primary Language __________________________________

 

Is your child toilet trained?              _____ yes       _____ no

 

Does your child nap?                 _____ yes       _____ no. If so, when?  ____________________

 

Describe any school or play-group experiences in which your child has participated:

 

 

 

Please include any additional pertinent information about your child:

 

 

 

 

Did anyone refer you to the program?

 

 

 

Do any of the following conditions apply to your family?

 
  ·         low family income                          

  ·         free and reduced lunch                           

  ·         family member with disability

   ·         primary language other than English                            

   ·         parent does not have high school diploma

   ·         screened for special education (not qualified)

   ·         chronic stresses; family stresses

   ·         behavior problems at home or in the community

   ___  none            ___  1              ___  2 or more

                                                                                                             
                                                                                                                                                    For office use only:       Date received  _______________

                                                                                                                                                                                         # on application  _____________