2021-2022 Clarksburg High School Coyote Pups Child Development Preschool INTEREST FORM

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Information regarding the PROJECTED Days and Hours for the 2021- 2022 school year has NOT YET been determined by Montgomery County Public Schools . Our Preschool MAY or MAY NOT be available, but to prepare for the year *JUST IN CASE*, Clarksburg Coyote Pups Preschool has decided to take a list of names and student information

COMPLETION OF THIS FORM DOES NOT GUARANTEE THAT YOUR CHILD HAS BEEN PLACED IN THE 2021 - 2022 ROSTER! There is NO GUARANTEE that the program will open in either the Fall or the Spring semester

This is an INTEREST ONLY form, and all information provided will only be used for that purpose.
If MCPS decides that a ECD Preschool Program will be allowed to open, you will be contacted to determine your continued interest in enrolling your child. Thank you for completing this form, an we look forward to serving you and your child soon.

Thank you for your interest in the Clarksburg High School Child Development program!

Email *

Child's LAST NAME *

Child's FIRST NAME *

Prefers to be called: *

Gender at birth *

Female

Male

Option 3

Birth Date *

YYYY

Home Address *

Home Phone (EVENING) *

Child lives with (please check all that apply): *

Both Birth Parents

Mother

Father

Maternal Grandparent(s)

Paternal Grandparent(s)

Other Extended Family

Multiple Households

Older Siblings

Younger Siblings

Required

Parent/Guardian Contact 1 Name: *

Parent/Guardian Contact 1 Cell Phone Number: *

Parent/Guardian Contact 1 Email: *

Parent/Guardian1 Daytime Phone Number: *

Parent/Guardian 1 Occupation: *

Parent/Guardian 1 Relationship to Child: *

Parent/Guardian 2 Name: *

Parent/Guardian 2 Cell Phone Number: *

Parent/Guardian 2 Email: *

Parent/Guardian 2 Daytime Phone Number: *

Parent/Guardian 2 Occupation *

Parent/Guardian 2 Relationship to Child *

List ALL Siblings: Name(s), Gender(s), and Age(s) as of 10/19/2021 (Included ages of EACH sibling, please) *

Ethnicity/Heritage:

Holidays Celebrated by Child/Family:

Primary Language at Home: *

Other Languages Spoken by the Child: *

Describe any PREVIOUS school setting that your child participated in: *

Health/ Allergy Concerns: *

Food/Dietary Concerns: *

Is there anything special that you'd like for us to know about your child?

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