Regina Early Childhood Application Form
This form is designed to take-in information about each child enrolling into the Regina Early Childhood Center.
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Email *
This application is being submitted for: *
Required
Attendance Preference(s)
Note: Tuition is current as of 2023-24 school year. Tuition subject to change.
 *
Required
Child's Identification Information
Please use Full Legal Name of Child
Legal Last Name of Child *
Legal First Name of Child *
Nickname of Child
Gender of Child *
Birthdate of Child *
MM
/
DD
/
YYYY
Race of Child *
Required
Ethnicity of Child *
Required
Family Information: Parents/Guardians
Parent's/Guardian's Religious Denomination(s) *
Please indicate if you attend any of the parishes affiliated with Regina Catholic Education Center: *
Required
Expected Year for Regina Kindergarten Admissions? *
Required
Parent/Guardian #1 Name *
Parent/Guardian #1 Home Address (Street, City, State, Zip) *
Parent/Guardian #1 Place of Employment *
Parent/Guardian #1 Cell Phone Number *
Parent/Guardian #1 Work Phone Number *
Parent/Guardian #1 Primary Email Address of Correspondence *
Parent/Guardian #1 status *
Parent/Guardian #1 *
Required
Parent/Guardian #2 Name
Parent/Guardian #2 Home Address (Street, City, State, Zip)
Parent/Guardian #2 Place of Employment
Parent/Guardian #2 Cell Phone Number
Parent/Guardian #2 Work Phone Number
Parent/Guardian #2 Primary Email Address for Correspondence
Parent/Guardian #2 status
Parent/Guardian #2
Names and ages of siblings and/or other children in the family (if any): *
Emergency Contacts
Provide information for the people who are allowed to pick up your child from school and that we are allowed to contact in case of an emergency (besides the parents/guardians listed above).
Emergency Contact #1 Name (needs to be someone other than the parents/guardians listed above) *
Emergency Contact #1 Relationship to Child *
Emergency Contact #1 Cell Phone Number *
Emergency Contact #1 Other Phone Number (please label: work, home, etc.)
Emergency Contact #2 Name
Emergency Contact #2 Relationship to Child
Emergency Contact #2 Cell Phone Number
Emergency Contact #2 Other Phone Number (please label: work, home, etc.)
Emergency Contact #3 Name
Emergency Contact #3 Relationship to Child
Emergency Contact #3 Cell Phone Number
Emergency Contact #3 Other Phone Number (please label: work, home, etc.)
Play and Sociability
How does your child get along with other children? *
His/Her usual playmates are...(check all that apply) *
Required
Does your child have any previous group experience? *
Required
Personality and Emotional Development
Does she/he accept new people easily? *
What do you notice your child gets anxious or nervous about? *
What nervous habits does your child have? *
When you find it necessary to discipline your child, how do you do so? *
Medical / Health Information
Is your child toilet-trained? *
Definition of Toilet-Trained at Regina: Independently pulls pants/underwear up and down. Uses the toilet for both urinating and stooling. Uses toilet paper to clean themselves independently after using the toilet. Recognizes when they need to use the toilet and uses words to communicate to someone that they need to use the toilet.
Does your child nap at home? If so, how often and how long? *
List any known allergic reactions, medically prescribed diets, food sensitivities, skin sensitivities, physical limitations, or other special medical conditions your child has: *
Has your child ever been screened or tested for any neurological, social, or behavioral disabilities and/or disorders? Have they ever participated in any Special Education services or programs? If so, please specify said screenings, tests, services and/or programs. *
Language & Communication
What is the primary language spoken in the child's home? *
Does your child speak any other languages besides the primary language spoken in the home? *
Does your child speak in complete and full sentences? *
Does your child talk with someone in conversation with at least 2 back-and-forth exchanges? *
Other Information:
What are some of your child's favorite games, activities, and interests? *
Provide any other information you believe will be helpful to us in understanding and assisting your child and family. *
The application fee for the Regina Early Childhood Center is $100 per student, payable at the time of application submission. Payments are accepted via cash, check, or credit card.

Cash or check may be mailed or delivered to the Elementary Office with "Attn: Michala Cox" written on the envelope to ensure receipt. Contact ECC Director, Michala Cox with any questions at michala.cox@regina.org.
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