*First Name:
*Last Name:
*Date of Birth:
    Year
    Month
    Day
School (if applicable):
Grade (if applicable): Pre-K K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
*Gender: Male Female Other
Pronouns:
*Is the child fully potty trained: No Yes
Does the child have an IEP or need 1-on-1 support for self-help skills or behaviors? No Yes
If yes, please briefly explain:
*Starting term: School Year 2024-2025 School Year 2025-2026
*Type of Program: Elementary Preschool 4k
*Days attending: Monday Tuesday Wednesday Thursday Friday
*Do you qualify for free/reduced lunch? No Yes
*Phone:
*Email: