Preschool Lab Program
(sessions subject to change)
Please check preferred session.
_________ 3 year olds (T/TH)
__________ 4 year olds (M/W/F)
Date received __________ (office use)
Child's Name________________________________________________________________________
(Last) (First) (Middle) (Nickname)
Child's Birthdate_________________________ Current Age ___________ Gender __________ Month/ Day/ Year
Parent/Guardian Names_______________________________________________________________
Elementary School child will be attending (if known)________________________________________
Address: (Please include street name)
___________________________________________________________________________________
___________________________________________________________________________________
E-mail Address_______________________________________________________________________
Telephone Numbers :
Home ___________________________ Cell_______________________________________________
Other_______________________________________________________________________________
Other Persons at Home Age Relationship
______________________________________ __________ _________________________
______________________________________ __________ _______________________ __
______________________________________ __________ _________________________
______________________________________ __________ _________________________
Languages Spoken at Home ___________________________________________________________
List any health concerns _______________________________________________________________
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