Child's Full Name

Child's Date of Birth

Child's Gender Child's GenderMaleFemale

Preferred Start Date

Second Child's Full Name

Second Child's Date of Birth

Second Child's Gender Second Child's GenderMaleFemale

Preferred Start Date

Mother's Name

Mother's Address

City

State

Zip

Mother's Phone Number

Email Address

Father's Name

Father's Address

City

State

Zip

Father's Phone Number

Email Address

Does child reside with both parents? Does child reside with both parents?YesNo

If no, do you have shared custody? If no, do you have shared custody?YesNo

Do you (or did you ever) have a child enrolled in First Steps Preschool? Do you (or did you ever) have a child enrolled in First Steps Preschool?YesNo

If yes, then please list names (siblings receive priority in placement)

Are you affiliated with or currently attending a local church? If so, where?

Is your child currently (or have they ever) attended preschool or group care? Is your child currently (or have they ever) attended preschool or group care?YesNo

If so, where?

Alternative Parental Contact Name (i.e. Legal Guardian)

Relationship to Child

Guardian's Address

Guardian Employer

Guardian Work Phone

Guardian Cell Phone

Digital Signature

Today's Date