Application

Child Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Caregiver 1 Name *

First Name

Last Name

Caregiver 1 Cell Phone *

(###)

###

####

Caregiver 2 Name

First Name

Last Name

Caregiver 2 Cell Phone

(###)

###

####

Would you judge your child to be *

Easily Managed

Fairly Easily Managed

Difficult to Manage

Does your child have or has had the following diseases?

Measles

German Measles

Scarlet Fever

Whooping Cough

Mumps

Chicken Pox

Poliomyelitis

Allergy

Heart Disease

Rheumatic Fever

Kidney Disease

Diabetes

Convulsions

Epilepsy

Aids

Infectious Hepatitis

Is your child presently taking any medication on a regular basis? *

Yes

No

Are you familiar with the Reggio Emilia Approach or Project Approach? *

Yes

No

Are you a member of the First Presbyterian Church? *

Yes

No

Tuition Grants are available for those in need. Are you interested in applying for a grant? *

Yes

No

Today's Date *

MM

DD

YYYY