Must Be 3Years Old by September 30 of the Academic Year Applying.

PRESCHOOL APPLICATION

(Must be 3years old by September 30 of the academic year applying.)

NOTE: You are expected to update application as information provided by you changes.

Applications will be kept on file for one academic year.

Date of Application ______Requested Admission Date ______

Child's Name ______

Gender:______Birthdate _____/_____/_____Present Age____

Parent/Guardian Name(s) ______

Contact information: Home/cell phone ______Home/cell phone ______

Work phone ______Work phone ______

Email ______Email ______

Home Address:______

Number Street Apt. No.

______

CityStateZip

KSU AFFILIATION – Affiliation will be verified using the online KSU phone directory and student information systems. If not listed, please submit appropriate documentation verifying status with this application.

Parent/ Guardian Name / Circle all that apply / KSU
Department / Circle PT or FT / Check here if not KSU Affiliated
Undergraduate student Graduate student Faculty Staff Visiting Scholar Alumni / Part time
OR
Full time
Undergraduate student Graduate student Faculty Staff Visiting Scholar Alumni / Part time
OR
Full time

Child’s previous preschool experience ______

Is this child toilet trained at this date? Yes _____ No ______(children must be toilet trained by the first day of enrollment)

Any special needs of child (physical health or development)? ______

If yes, does your child have a current IFSP/IEP? Yes_____ No ______

Sibling(s) attended/attending CDC and dates of attendance:

Name / Dates of attendance / Name / Dates of attendance

Please indicate your intended payment method:

______pay out of pocket______KSU payroll deduction ______subsidized by county

The Center hours are 7:00 a.m. to 5:30 p.m. Please write in child’s anticipated arrival and departure times (e.g. 8:30-12:30, 8:00-5:00, etc.) in the appropriate column.

If indicating more than one option,it is very helpful to indicate #1, 2, 3… choices.

Tues/ThursMon/Wed/FriMon thru Fri

Full-Day______

Half-Day (AM ONLY)______

No preference/ would be interested in anything available: half-day_____ full-day______

*OPTIONAL: The Child Development Center encourages applications from families of diverse backgrounds and experiences. The following information is valuable in ensuring a diverse population of children.

How do you identify? (Mark all that apply.)

___ American Indian or Alaska Native ___ Asian ___ Black or African American

___ Native Hawaiian or other Pacific Islander ___ White ___ Other: ______

Do you identify as Hispanic or Latino? Yes _____ No ______

Language(s) spoken at home? ______

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FOR OFFICE USE ONLY: Date Received ______Acknowledgement Sent ______Acceptance Sent ______

PLEASE RETURN THE COMPLETED APPLICATION TO:

ChildDevelopmentCenter, Attn: Pam Hutchins, KentStateUniversity, PO Box 5190, Kent, OH 44242-0001