Application Form
Applying for the Academic School Year
20__ /__
*Application must be accompanied by a $50.00 Application Fee.
*Please make your checks payable to Rehoboth Cooperative Preschool.
*This fee is Non-Refundable.
(Circle One) I am enrolling my child in the: 2 Year Old Class 3 Year Old Class 4 Year Old Class
Child’s Information (Part 1):
Child’s Name (First & Last): _______________________________________________________
Nickname (if any): __________________________ Male or Female: _____________
DOB: (M/D/Year) ____ / ____ / ____
Home Phone: (____) _____ - _____
Birthplace: ______________
Address: _______________________________
Left or Right Handed: _________
_______________________________
Allergies _______________________
_______________________________ ______________________________
Family Information (Part 2):
Names of Siblings Age of Siblings Child Lives With (Check All that Apply):
__________________ _______ Mother ______ Relatives______
__________________ _______ Father ______ Other _____
__________________ _______
__________________ _______
Parent/Guardian Information (Part 3):
Parent’s Martial Status: (Please Circle One) Married Separated Divorced Widowed
Mother/Guardian Name: _________________________________ Occupation: ____________________
Home Address & Phone (If different from child): Work Address & Phone:
__________________________________ ______________________________
__________________________________ ______________________________
__________________________________ ______________________________
Cell Phone: (_____) _____ - ______ (_____) _____ - ______
E-Mail: ______________________
Father/Guardian Name: _________________________________ Occupation: ____________________
Home Address & Phone (If different from child): Work Address & Phone:
__________________________________ ______________________________
__________________________________ ______________________________
__________________________________ ______________________________
Cell Phone: (_____) _____ - ______ (_____) _____ - ______
E-Mail: ______________________
I hereby make an application to Rehoboth Cooperative Preschool for the named child. I have read and completed this application to the best of my ability and knowledge.
Signature: __________________________________ Date: ___________________
Thank You for your interest in Rehoboth Cooperative Preschool!
Administrative USE ONLY: Date and Time Application Received: _______________________
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