Application for Enrollment/Waiting List

Child's Name *

First Name

Last Name

Sex *

male

female

Date of birth *

MM

DD

YYYY

Home address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/guardian #1 *

First Name

Last Name

Lives at home with child? *

yes

no

Cell phone *

(###)

###

####

Work phone

(###)

###

####

Parent/guardian #2

First Name

Last Name

Lives at home with child?

yes

no

Cell phone

(###)

###

####

Work phone

(###)

###

####

Requested start date

MM

DD

YYYY

Requested schedule

5 days (MTWThF)

3 days (varies)

2 days (TTh)

Food allergies

milk

nuts

wheat

other

Animal allergies

cats

dogs

bees

other

Does child have medication that will need to be administered at school? *

Yes

No

Does child have an IEP? *

Yes

No

Is child receiving services through Lanterman Regional Center? *

Yes

No