Child's Full Name *

Child's Date of Birth *

Child's Gender * Child's Gender *MaleFemale

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 (TYPE NAME) *

Today's Date *