Application: Li'l Lions Preschool Step 1 of 3 - Child & Parent Information 33% Page 1 of 2 - Child & Parent InformationCHILD INFORMATIONChild's Name* First Middle Last Birth Date* MM slash DD slash YYYY Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 3-year-old Program: Child's Age on October 15 of THIS calendar year 4-year-old Program: Child's Age on October 15 of THIS calendar year PROGRAM OF CHOICENursery School (Age 3) Options : (2 days) Tues./Thurs: Half Day (8:00AM - 11:30AM) (2 days) Tues./Thurs: Full Day (8:00AM - 2:30PM) (5 days) Mon.-Fri.: Full Day (8:00AM - 2:30PM) Preschool (Age 4) Options: (3 days) Mon./Wed./Fri.: Half Day (8:00AM - 11:30AM) (3 days) Tues./Thurs: Full Day (8:00AM - 2:30PM) (5 days) Mon.-Fri.: Full Day (8:00AM - 2:30PM) PARENT INFORMATIONFATHER/Guardian's Name* First Last Father's Home Address (if different from child's): Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Father's Cell Number:Father's Occupation Father's Employer Father's Email MOTHER/Guardian's Name* First Last Mother's Home Address (if different from child's) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mother's Cell Number:Mother's Occupation Mother's Employer Mother's Email* Child lives with:* Both Parents Father Mother Guardian Other Legal custody belongs to:* Both Parents Father Mother Guardian Other All correspondence should be sent to:* Both Parents Father Mother Guardian Other Person responsible for tuition and expenses:* What church, if any, does your family presently attend?* PREVIOUS CHILD CARE INFORMATIONHas your child previously been in childcare?* Yes No 1. Name of facility/program (if yes): Child Care Program Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Primary Caregiver at this program: From: MM slash DD slash YYYY To: MM slash DD slash YYYY 2. Name of facility/program: Child Care Program Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Primary Caregiver at this program: From: MM slash DD slash YYYY To: MM slash DD slash YYYY ABOUT YOUR CHILDDoes your child have any special needs?* Yes No If yes, please explain:Explain what we ought to know about your child as a learner and as a person:Sibling Name & Age: Sibling Name & Age: Sibling Name & Age: Sibling Name & Age: How did you hear about Lil' Lions Preschool?* Please list your reasons for selecting Lil' Lions Preschool:*PARENT/GUARDIAN AFFIRMATIONMy signature affirms that the information provided in the application materials is complete and accurate.FATHER/GUARDIAN: Please type your full name as a signature. By completing this form you agree that the information above is complete and accurate to the best of your knowledge: MOTHER/GUARDIAN: Please type your full name as a signature. By completing this form you agree that the information above is complete and accurate to the best of your knowledge: Thank you for applying! There is a $150 nonrefundable Registration Fee required in order to hold your child's place in the preschool. You may pay online by selecting "Credit Card" below, or choose the "Check" option and mail or bring your payment to the school.Payment Method Credit/Debit Card Check Registration FeeTotal $0.00 Credit Card*Card Details Cardholder Name