ENROLLMENT APPLICATION Childs' Name Date of Birth01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2025202420232022202120202019201820172016201520142013201220112010year Age GenderMaleFemale If Yes, Where and for How long? Has your child been to a Preschool before?Please check the appropriate program Schedule & Meal PatternFull Time 5 days a week Monthly $Full Time 5 days Weekly $Full Time 5 daysPart Time 3 days a week* Monthly $Part Time 3 days Weekly $Part Time 3 daysPart Time 2 days a week* Monthly $ Part Time 2 days Weekly $Part Time 2 days Matrix(1)MondayTuesdayWednesdayThursdayFridayBreakfastLunchSnackHours of Care (ex9-5) Request starting date How did you hear about usPARENT / GUARDIAN INFORMATIONMother's Information Mother's Name Social Security # DL # Address City State Zip Email Home Phone Place of Employment Cell Phone Job Title Work Phone Marital StatusSelect valueSingleMarried Custody InformationFather's Information Father's Name Social Security # father DL #father Addressfather Cityfather Statefather Zipfather Emailfather Home Phonefather Place of Employmentfather Cell Phonefather Job Titlefather Work Phonefather Marital StatusfatherSelect valueSingleMarried Custody Informationfather List any allergies your child has My child excels in My child needs help in Parent's evaluation of child's personality Does your child have any special needs/problems/fears? Additional information we should know about your childReturn this completed application with your enrollment fees as soon aspossible to reserve your child's space. Enrollment fees do not include yourfirst week's tuitionI understand I am signing up for specific days and times and I am responsible for Payment according to the school policyI understand that the enrollment fees are non-refundable. Date Parent/Guardian's SignatureClearVillage Preschool Academy Infant & Preschool Infant Needs and Services Plan Childs Name: Birth Date: 01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Todays Date:This form is to be completed then updated quarterly. Parents please bring any formula, bottles,cups, food labeled with your child's name and the date. All bottles of formula must be premixed as staff are not permitted to prepare formula.Feeding Plan 1. Is your child on a special diet? YesNo If yes please specify: 2. Does your child have any allergies? YesNo If yes, please list: 3. Are there any foods your child should not eat for medical, personal, or religious reasons? 4. Does your child use a bottle?YesNo What do you put in the bottle: 5. My child uses a: Fork Spoon Bottle Cup 6. Special likes and dislikes: 7. Feeding Schedule 8. Timeline to introduce solids and specific consistency offoods:Safe Sleeping Plan 1. What is your child's normal sleeping environment? 2. What is your child's normal sleeping schedule and habits? 3. What are your child's rolling abilities at this time?*please note we are not permitted to use swaddles/blankets/other loose items in cribs*Parents are to bring one crib sheet and to be sent home on Fridays. We change sheets daily and will provide sheets for the rest of the week. Toileting Plan 1. How many wet diapers a day approx.: 2. How often does your child have a bowel movement: 3. Any special comments or concerns in reference to diapering/toileting: 4. Method preferred for toilet training: 5. Specific equipment used and time line of use as directed/provided by parent as well as a timeline of introduction of appropriate clothing:All parents are asked to please provide diapers and wipes for their child, as well as any ointments, powders, etc. that may be preferred by the parent. Please make sure all supplies areclearly labeled with your child's name. I have discussed my infant's needs and services plan with the center's Director and agree withthe information provided here. I will notify the Director immediately of any changes in the needsof my child. Parents Name Date(Toilet planing) Center Representative: Daytime Phone# : Date(Toilet planing 2) Signature (Toilet planing)ClearVILLAGE PRESCHOOL ACADEMY 18052 Imperial Hwy.Yorba Linda, CA 92886Phone : 714-993-3444Fax : 714-993-3470 Village Preschool Academy uses Remind, a text messaging service, to send out important reminders and/or safety alerts if ever needed. If you would like to be signed up for Remind text messages please provide your Name and preferred cell phone number below. One or both Parents are welcome to sign up. Please be aware this is a one way form of communication, no responses to Remind messages will be received by Village Preschool Academy. Please always call the center directly or stop by the office if you have any questions or concerns. Child's Name: Classroom: Contact 1 Contact 1 Name Contact 1 Cell Phone #Contact 2 Contact 2 Name Contact 2 Cell Phone #Infant and Toddler Supply ListParents please make sure to supply your child's teacher with the following supplies. If your child is running low on a specific item they will notify you verbally or by sending home an "Oh No" report which will indicate which item/items they are running low on. Thank you for your support and cooperation! 1 Crib sheet- to be sent home on Fridays for laundering. We will provide sheets for the rest of the week. At least 1 pair of extra clothes. Diapers/Wipes and any other diapering supplies your child may require such as powder, ointment, etc. Infants only- 1 blanket for tummy time, also to be sent home on Fridays for laundering. Infants only- Bottles and either formula or breast milk, as we do not supply food for the infants. We also ask that infant/toddler parents provide a couple family photos for the children so that teachers can use them in the classroom. Please remember any item brought into the infant/toddler classroom MUST be labeled with your child's name. Any food or bottle item should be labeled with the child's ·name as well as the date it was brought in your child's teacher can assist you with this. SubmitReset
