Information About the Child:
Child's Name
________________________________________________________________________
First
Middle
Last
Name Usually Called________________________________________
Address_____________________________________________________________________________
_____________________________________________________________________________
Telephone (_______) _______ - ____________
Date of Birth _________ / _______ / ___________
Information About the Mother:
Mother's Name____________________________________
Employer____________________________________________________________________________
Employer's
Address___________________________________________________________________
___________________________________________________________________
Work Phone (______) _________ - ____________
Information About the Father:
Father's Name____________________________________
Employer____________________________________________________________________________
Employer's
Address___________________________________________________________________
___________________________________________________________________
Work Phone (______) _________ - ____________
Please list siblings in your family, and their ages:
Playschool Schedule Desired: (please check one)
___ Full Time (3-5 days), 7:00 a.m. to 6:00 p.m.
___ Part Time (2 days), 7:00 a.m. to 6:00 p.m.
___ Flex Time 7:00 a.m. to 6:00 p.m.
How many days per week?
____ Which specific days?
_________________________
Please write a short description of your child on the reverse side of
this page. Include group experiences he or she may have had, and what
expectations you have regarding your child's school experience.
AFTER YOU HAVE COMPLETED THIS FORM, PLEASE MAIL IT TO:
Presbyterian Hospital Infant & Child Care Center
61 Haven Avenue
New York, NY 10032 |
