Child's Legal Name
*
First Name
Last Name
Age at start of school (year/ month)
Date of birth
MM
DD
YYYY
Address Line (please include apartment number)
*
City
*
Zip Code
*
Name of Parent or Guardian #1
*
First Name
Last Name
Phone number of Parent or Guardian #1
*
(###)
###
####
Email Address of Parent or Guardian #1
*
Profession of Parent or Guardian #1
*
Name of Parent or Guardian #2
If applicable
First Name
Last Name
Phone Number of Parent or Guardian #2
If applicable
(###)
###
####
Who is the best person to contact to schedule tour and play group?
*
Parent or guardian #1
Parent or guardian #2
Is your child currently enrolled in a preschool?
*
Names, ages and schools of siblings
If applicable
Has your child received any early intervention or special education services?
*
Yes
No
Please list all therapies your child has received
If applicable
Who referred you to Merricat's?
First Choice Option
*
The half day program is 2½ hours. The full day program is six hours, including a one hour lunch and rest. You may choose a combination of full and half day sessions.
Second Choice Option
*
Do you have flexibility with your scheduling?
*
