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Preschool Application Form
for the 2010-2011 School Year.

Please submit one form per child.

Have you been with us before?*	Current Family Former Family New Family
Please choose*	2010-2011 (Does not guarantee a spot.) 2011-2012 Mailing List only (Does not guarantee a spot.)
Child's Birthday*	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2004 2005 2006 2007 2008 2009
Gender*	Boy Girl
Child's Name*	First: Middle: (optional) Last
Name to be used at school
Child's Address*
City, State, zip*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Parent/Guardian Information
Parent/Guardian Name*	First Name: Last Name:
Relationship to Child*	Please Select Mother Father Step Mother Step Father Aunt Uncle Family Friend Foster Parent Grandmother Grandfather Legal Guardian
Parent/Guardian Occupation
Parent/Guardian E-mail*
Parent/Guardian Home Phone
Parent/Guardian Cell Phone For Emergency Contact
Place of Business
Business Phone For Emergency Contact
Additional Parent/Guardian Information
Parent/Guardian Name	First Name: Last Name:
Relationship to Child	Please Select Mother Father Step Mother Step Father Aunt Uncle Family Friend Foster Parent Grandmother Grandfather Legal Guardian
Occupation
E-mail
Home Address If different from Child's Address
City, State, Zip	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Home Phone
Cell Phone For Emergency Contact
Place of Business
Business Phone For Emergency Contact
Additional Information
Names & Ages of Siblings
Additional Information that would help us know your child better or meet your scheduling needs.
Where did you hear about our program?	Web Lincoln Kids Free Times Word-of-mouth
Optional Sponsor a Child	I (We) would like to contribute an extra $10 each month to help a child who needs financial assistance. (This is a tax-deductible contribution). Thank You.
Assistance	I (We) would like to apply for the Tuition Assitance Program. To qualify, your income must be within the guidelines used by the Free or Reduced School Meals Program. Please call our office at 476-8304 for a form or to discuss emergency circumstances.
Session Information
Early Morning Session Designed to use before morning Preschool sessions. (Available from 7:30 - 9:15 AM) What time do you wish to bring your child?
	Monday Tuesday Wednesday Thursday Friday I am flexible with these times. No Yes
Preschool Sessions* List choice of session from 1-5 (1 = 1st choice, etc.)	Mon / Wed / Fri North Room 9:00-11:30 9:00-2:00 12:45-3:15 South Room 9:15-11:45 9:15-2:15 Tue / Thur North Room 9:00-11:30 9:00-2:00 South Room 9:15-11:45 9:15-2:15 Mon - Fri North Room 9:00-2:00 South Room 9:15-2:15
Late Afternoon Session Designed to extend Preschool sessions (Available until 5:30 PM) Do you want your child to take a nap? No Yes What time do you wish to pick up your child?
	Monday Tuesday Wednesday Thursday Friday I am flexible with these times. No Yes
A non-refundable Registration Fee of $50.00 will be billed at the time you accept a spot.

Current families have priority for enrollment. After March 4, applications from new families will be processed based on date of receipt and available spaces remaining.

Confirmation and/or waiting list letters will be sent after March 10th.

Note: Fields marked by an asterisk (*) are required.