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Request a Screening Appointment
This form will add your information to our list of students requesting a screening appointment. The screening is the first step to becoming eligible to enroll at Player School. *NOTE: You must be a resident of District 109.
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* Indicates required question
1. Child's Name (First and Last)
*
Your answer
2. Mother's Name (First and Last)
*
Your answer
3. Father's Name (First and Last)
*
Your answer
4. Child's Date of Birth
*
MM
/
DD
/
YYYY
5. Address (include apartment number if applicable); City, State, Zip Code
*
Your answer
6. Preferred Phone Number
*
Your answer
6. Alternate Phone Number (if applicable)
Your answer
7. Email Address
*
Your answer
8. Child's Gender
*
Male
Female
9. Is another language spoken at home?
*
No
Yes
10. If yes, what language is it?
Your answer
11. Do you have any concerns for your child? (speech, social-emotional, general development, etc.)
Your answer
12. Names and ages of child's siblings:
Your answer
13. Has your child ever attended a preschool or daycare program?
Yes
No
Clear selection
14. If yes, please enter name of program
Your answer
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