Preschool Enrollment Form

warning: strtotime() [function.strtotime]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.
warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.
warning: strtotime() [function.strtotime]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.
warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.
warning: strtotime() [function.strtotime]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.
warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.
warning: strtotime() [function.strtotime]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.
warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'America/Chicago' for 'CDT/-5.0/DST' instead in /home/littlela/public_html/modules/webform/webform.module on line 3374.

Please fill out the fields on the form below. We will be in touch with you shortly once you submit the form.

Student Information

Please enter information about the student or child in this area.

Child's Date of Birth: *

Please enter the child's date of birth.

Gender: *

Please select the child's gender.

Child's First Name: *

Please enter your child's first name.

Child's Middle Name:

Please enter your child's middle name.

Child's Last Name: *

Please enter your child's last name.

Child's Nickname:

Please enter your child's nickname, if they use one.

Child's Street Address:

Please enter the street address for the residence of your child.

Child's City:

Please enter the city of residence for your child.

Child's State:

Child's Zip Code:

Please enter the 5 digit zip code for the child's residence.

Date of Baptism:

Please enter the Date of Baptism for this child, if applicable.

Home Church:

Please enter the name of the child's home church.

Parent Information

Please enter this information about the parent filling out this form, here.

Name: *

Please enter your first and last name.

Email Address:

Please enter your email address, if you have one. We respect your privacy, we only use your email address to contact you in response to this form.

Phone:

Please enter your phone number with area code, for example ###-###-####.

How would you like us to contact you?: *

Please select how you would like us to contact you.

Days and Hours of Care

To be in the 3 year old program, the child must be 3 before September 1st. To be in the 4 year old program, the child must be 4 before September 1st.

Program: *

3 Year Old Tuesday 9:00-11:30AM

3 Year Old Thursday 9:00-11:30AM

3 Year Old Tues/Thurs 9:00-11:30AM

4 Year Old Mon/Weds 9:00-11:30AM

4 Year Old Tues/Thurs 12:30-3:00PM

4 Year Old Fri 9:00-11:30PM

Please select which preschool program you would like this child in.

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