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Pre-Application for Early Learning Center Preschool 21-22 school year.
Admittance to preschool is based on review of application and classroom availability. Your application will be electronically date stamped upon completion.
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* Indicates required question
Email
*
Your email
Name of Person completing application
Your answer
Relationship to Child?
Your answer
STUDENT DATA
Students Last Name
*
Your answer
Students First Name
*
Your answer
Students Middle Name
*
Your answer
Gender
*
Male
Female
Age
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
PARENT/GUARDIAN INFORMATION
Parents Name
*
Your answer
Street Address (within SWL District boundaries)
*
Your answer
City
*
Your answer
Zip code
*
Your answer
Cell phone
Your answer
Home phone
Your answer
Work phone
Your answer
Medical/Birth History & Development
Are there any medical issues (physical or emotional) which the preschool team should be aware of? (ADD/ADHD,Autism,Behavior, academic, syndromes, etc.)
*
Your answer
Please list any Surgeries or Hospitalizations (for any reason)
*
Your answer
Were there any complications at birth? if yes, please explain
*
Your answer
Type of birth (check all that apply)
*
Natural birth
C-section
Single birth
Twins
Multiple births
Required
Discharged with mom? if no, please explain.
*
Your answer
Birth weight?
*
Your answer
Sat alone at what age?
*
Your answer
Crawled at what age?
*
Your answer
Walked at what age?
*
Your answer
Is your child receiving any therapies -i.e; speech, OT, behavioral?
*
yes
no
Has your child been previously evaluated for Special Education by the SWL preschool?
*
yes
no
My child can separate from his/her parent.
*
yes
Other:
Has your child been involved in activities outside of family (i.e. church,sports)?
*
yes
no
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