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Evans Waitlist Form

Please fill out the form in it entirety. If any particulare section does not apply, please notate "no" or "none". Thank you.

"*" indicates required fields

Desired Start Date*

MM slash DD slash YYYY

Childs Information

Name of Child*

First Last

Date of Birth*

MM slash DD slash YYYY

Gender*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent's Primary Email*

(For internal correspondence only)

Name of Elementary School Attending*

(if any)

Parent Information - Mother / Guardian

Name*

First Last

Phone*

Email

Home Address (if different from child)

Street Address Address Line 2 City State ZIP Code

Employer*

Work Hours

Employer Address*

Street Address Address Line 2 City State ZIP Code

Work Phone*

Parent Information - Father / Guardian

Name*

First Last

Phone*

Email

Home Address (if different from child)

Street Address Address Line 2 City State ZIP Code

Employer*

Work Hours

Employer Address*

Street Address Address Line 2 City State ZIP Code

Work Phone*

Family Information

Marital Status of Parents*

Brothers & Sisters

Stepfather's Name

Stepmother's Name

Is your child adopted?*

Yes

No

Do they know?

Yes

No

Childs Living Arrangments*

Both Parents

Mother

Father

Other

Childs Legal Guardian(s)*

Both Parents

Mother

Father

Other

Are there any family situations that West Haven should be aware of?*

Health Information

Please list any and all allergies:*

Please list any dietary restrictions:*

What protocol should be taken if an allergic reaction occurs to the listed allergies above?

Please list any medication(s) prescribed for long-term use

Please list any general health issues we should be aware of including any mental health disorders or developmental disabilities.*

Name of individual completing enrollment*

First Last

Parental attestation to enrollment information*

I hereby attest that all the information I have provided herein is true and accurate to the best of my knowledge and that I shall notify West Haven of any changes in a timely manner.

Parental agreement to policies*

I acknowledge that I have received a copy of West Haven Preschool’s parent handbook, read it in its entirety, and agree to comply with the policies therein. I further agree that I have received a copy of West Haven Preschool’s tuition costs, to include additional fees and withdrawal requirements, and agree to comply with the statements therein.

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Name

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