Child Applicatant Name First Middle Last Parents NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneWill you be using our after school Day Care for your child?Does your child have responsibilities/work chores to take care of at home?If yes, what are they?Is your child presently under the care of a physician?Is he/she receiving any medication?Please check any of the physical difficulties listed below which pertain to your child: Allergy Hearing Difficulty Vision Difficulty Speech Problems Name of pre-school(s)My child currently attends Transitional/DiscoveryKindergarten Kindergarten Preschool Other How many days a week does your child currently attend school?Please check any of the following that apply My child prefers to play alone My child prefers to be with adults My child prefers to play with others What kind of play activities does your child enjoy most?Can your child be away from his/her parents for 2-3 hours without being upset? Yes No Can your child leave his/her parents without reluctance? Yes No Is your child afraid of going to school? Yes No Is your child able to meet new adults without shyness? Yes No Does your child follow adult direction without complaint? Yes No Does your child typically use complete sentences when communicating ? Yes No Does your child clean up after him/herself? (toys, crayons, etc.) Yes No Can your child tie his/her shoes? Yes No Can your child dress him/herself? (use zippers, buttons, snaps, etc.) Yes No Does your child demonstrate independence in personal care? (washing hands, brushing teeth, using the restroom) Yes No Does your child understand that choices result in positive/negative consequences? Yes No Does your child show a general understanding of times of day? Yes No Additional Comments This iframe contains the logic required to handle Ajax powered Gravity Forms.