Little Lions Preschool

Enrollment Form for 2015-2016

Thank you for applying to Plaza Heights Christian Academy Little Lions Preschool.
Please include a copy of the childs State Certified Birth Certificate and up-to-date Immunization
Records when submitting this application to the school office.
Childs Full Name ________________________________________________________________________
Name child will learn to write___________________ Birth Date ___/_____/___
Street Address

Age ____

Boy / Girl

City and Zip_____________________________

Phone

Church Membership________________________________________

Please mark your preference (Lion Kittens must be 3 BEFORE 8/1/15 Lion Cubs must be 4 BEFORE
8/1/15 Terrific Twos must be 2):
LION KITTENS:

2-day T/Th AM

3-day M/T/Th AM

2-day T/Th PM

3-day M/T/Th PM

LION CUBS: 3 day M/T/Th AM

2-day W/F Mid-Day

5-day All Day M-F

3 day M/T/Th PM

2 day W/F Mid-Day

5-day All Day M-F

Terrific Twos: Monday
AM & PM
Fathers Name

Tuesday

AM only

Wednesday

Thursday

Friday

PM only
Home Phone____________________________

Address ________________________________________ City and Zip ____________________________

E-mail Address _________________________________________________________________________
Occupation
Work Address
Work Phone
Mothers Name

Employer ___________________________________________
City and Zip______________________________
Cell Phone_____________________________________
Home Phone____________________________

Home Address __________________________________ City and Zip ____________________________

E-mail Address _________________________________________________________________________
Occupation
Work Address
Work Phone

Employer ___________________________________________
City and Zip_______________________________
Cell Phone_____________________________________

Office Use Only

Date Recd__________ Enrollment Fee Paid______ Sibling of Current Student____ Member of PHBC____
Tuition Management Fee Paid _________
Activity Fee Paid ________

How did you hear about us?

Website

Sign

Friend (name) _________________

Newspaper

Mailing

Other __________________________________________________
Physicians Phone___________________________

Physician

Please list any special health or physical conditions or learning needs of which we need to be aware?_____
_____________________________________________________________________________________
Allergies?____________________________________________________________________________
Date last examined by a physician ___________________ Has your child been to the dentist? _________
Please mark all that apply: Lives with both parents

Lives with father

Parents are separated

Parents are divorced

Lives with mother

Mother deceased
Father deceased

Names and ages of siblings:

____________________________________________________________________________________
Has your child or siblings attended Little Lions? ___ Name of teacher(s) _________________________
Has your child attended another early education center? ____ Where? __________________________
Describe any unusual home or custody situation: ____________________________________________
___________________________________________________________________________________

FIELD TRIP PERMISSION

I understand that special trips are planned for the children away from the school throughout the year. I am
aware that they will be carefully arranged and supervised by an adequate number of adults. I give my
permission for my child to go on these scheduled field trips and be transported by school bus or parent
vehicle.
____________________________________
Parents Signature

PUBLICITY PERMISSION
I do give permission for my child, _____________________________, to be photographed for purposes
of display in, but not limited to, the following: school publications, newspapers, bulletin boards, yearbook,
and the PHCA website.
I do NOT give permission for my child, _____________________________, to be photographed for
purposes of display in, but not limited to, the following: school publications, newspapers, bulletin boards,
yearbook, and the PHCA website.
____________________________________
Parents Signature