2022-2023 Adena Preschool Interest Form

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Adena Elementary Preschool is beginning the enrollment process for it's two 5-Star Step Up To Quality rated preschool classrooms for the 2022-2023 school year.

Please complete the information below and be sure to submit your form. Once this form has been completed, a member of our Preschool Staff will contact you with further information.

Collecting the following pieces of documents and having them ready when we call will be very helpful.
* Photo ID for Parent or Guardian
* Copy of Student's Birth Certificate
* Student's Immunization Records
* Custody Orders (if applicable)
* Proof of Income (for those applying for the ECE grant)
* Proof of Residency (official lease/rental agreement, property tax statement, utility bill within last 30 days, mortgage coupon/closing statement, or the Adena Local Schools Doubled Up form with notary seal)

Child's First Name *

Child's Last Name *

Child's Date of Birth *

YYYY

Child's Gender *

Male

Female

Parent/Guardian Name(s) *

Primary Parent Contact Number (please add area code) *

Primary Parent Email Address *

Child's Address *

Federal Poverty Guidelines - Use this chart to determine eligibility for the ECE preschool grant. If your gross household income falls at or below the listed income for the number of people in your household, you may qualify for a grant spot. Your income will be verified by the school.

Enrollment Options You Would Consider: (Check All That Would Apply) *

Full Day Classroom, 4 Days per Week, $200/month tuition

Full Day Classroom, 2 Days per Week, $120/month tuition

Full Day Classroom, 2 Days per Week, Grant (based on above income guideline)

Required

Additional Comments or Questions for Adena Elementary Preschool: *

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