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Pre School Application
Heartland Career Center
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* Indicates required question
Email
*
Your email
Preferred Preschool Time:
*
AM
PM
Child's name:
*
Your answer
Child's age:
*
Your answer
Child's Birth Date:
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Street Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip Code:
*
Your answer
Home Phone (if non-applicable enter N/A):
*
Your answer
Mother's Name (if non-applicable enter N/A):
*
Your answer
Mother Cell Phone (if non-applicable enter N/A):
*
Your answer
Text:
*
Yes
No
Mother Email:
*
Your answer
Father's Name (if non-applicable enter N/A):
*
Your answer
Father Cell Phone (if non-applicable enter N/A):
*
Your answer
Text:
*
Yes
No
Father Email:
Your answer
Father's Name (if non-applicable enter N/A):
*
Your answer
Mother's place of employment (if non-applicable enter N/A):
*
Your answer
Mother's place of employment phone number - Please include area code:
*
Your answer
Father's place of employment (if non-applicable enter N/A):
*
Your answer
Father's place of employment phone number - Please include area code:
*
Your answer
Option 1
Clear selection
Sibling 1
Your answer
Sibling 1 Age
Your answer
Sibling 2
Your answer
Sibling 2 Age
Your answer
Sibling 3
Your answer
Sibling 3 Age
Your answer
Sibling 4
Your answer
Sibling 4 Age
Your answer
Whom do we contact in case of an emergency (if you cannot be reached a:
*
Your answer
Emergency Contact:
*
Your answer
Emergency Contact address:
*
Your answer
Emergency Contact phone:
*
Your answer
Family Doctor:
*
Your answer
Family Doctor Phone:
*
Your answer
Medical Information:
*
Your answer
Special Medical Information:
Your answer
Special Interest:
Your answer
Authorized people (please include first and last name and reauthorized people (please include first and last name and relationship) :
*
Your answer
I certify that I am the parent/guardian of (Child's name) and I agree :
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Parent/Guardian (this represents the signature):
*
Your answer
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