Noah's Ark Preschool

Noah's Ark Preschool Application

Enter data using tab to go from one field to the next.

When finished, click on the "Submit" near the bottom of this page.

Child's Information

, Child's Name      Name to be used in school
     Last Name                                   First Name
 ,  
   Num           Street                                                                City                                                   ZipCode

Home Phone  required format aaa-bbb-nnnn   Sex Male Female        Birthday required format mn/dd/yyyy
Race/Ethnic Origin 
Email Address Needed to send you an acknowledgment!

Left or Right Handed  Right Left  Uncertain

Favorite play activities 

Parent's Information
Father
 , 
     Last Name                                   First Name
,   if different than child's
     Num           Street                                                                City                                                   ZipCode

Occupation
Employer's Name
 Work Phone    aaa-bbb-nnnn 
  Cell Phone   aaa-bbb-nnnn
 Email Address

Mother
 ,
     Last Name                                   First Name
,   if different than child's
     Num           Street                                                                City                                                     ZipCode

Occupation
Employer's Name
   Work Phone   aaa-bbb-nnnn 
    Cell Phone aaa-bbb-nnnn 
 Email Address

Day Care Provider
 Provider's Name    Phone aaa-bbb-nnnn 

Home Environment
 Is child adopted?   Yes No       Age at adoption   

Other Children in family
Name   Birthday mn/dd/yyyy         
Name   Birthday mn/dd/yyyy         
Name   Birthday mn/dd/yyyy         
Name   Birthday mn/dd/yyyy       

Are there any persons other than parents and siblings in the home? Yes No
If so, what are their roles in the life of the child?

Social Development 
Has child had previous group experience?Yes No  If yes, where?

Does the child have playmates? Yes No  

Does s/he get along well with other children? Yes No

Is s/he Hold down Ctrl key to select more than one

What do you expect for your child at preschool?

Emotional Behavior  Hold down Ctrl key to select more than one
Characteristic Behavior(s)

Religious Information
 Name of congregation mother attends  
Active Member? Yes No
If Not Listed, Choose Other and fill in box below
    
Include Church's Name and location
Name of congregation father attends    
Active Member? Yes No
If Not Listed, Choose Other and fill in box below
  
 Include Church's Name and location
Child(ren) attend(s) Sunday School?    Yes No     

Desired Class Selection           
Within your child's correct class age, enter 1 for first choice, 2 for second choice, and 3 for third choice

3 Year Old Full Day 

4 Year Old Full Day 

5 Year Old Full Day 
MTW     ThF MTW  ThF MTW  ThF 

All Full Day Classes include automatic enrollment in Lunch Bunch

 

3 Year Old 1/2 Day Classes

4 Year Old 1/2 Day Classes

5 Year Old 1/2 Day Classes
MTW AM      MTW AM   MTW AM  
MTW PM   MTW PM   MTW PM  
Wed PM   ThF AM   ThF AM 
ThF AM   ThF PM  
ThF PM  

 

Before Care, Lunch Bunch, and After Care
Drop-In for Before Care and After Care will require 24 hr advance notice. 

Drop-In for Lunch Bunch can be made on the day of service.

Choose as many Before Care, After Care, and Lunch Bunch days as you need. These selections are for regular daily usage.

Before School Care
8:00AM - School

Lunch Bunch
~11:30 AM -~12:30 PM

After School Care
School - 4:00 PM
Monday AM      Monday Noon     Monday PM     
Tuesday AM   Tuesday Noon   Tuesday PM  
Wednesday AM    Wednesday Noon   Wednesday PM  
Thursday AM   Thursday Noon   Thursday PM  
Friday AM    Friday Noon   Friday PM  


Emergency Medical Information
 Food Allergies  Enter None, if appropriate
Other Allergies  Enter None, if appropriate
Other Medical Info  Enter None, if appropriate

Source of Medical Care
 
  
   If Not Listed - Choose Other and fill in box below
  
   Include Clinic's Name, Phone #, etc.               

   Physician's Name 

Source of Dental Care
  
   If Not Listed - Choose Other and fill in box below
 
   Include Clinic's Name, Phone #, etc.

   Dentist's Name 

Choice of Hospital
 
   If Not Listed - Choose Other and fill in box below
             
    Include Hospital Name, Phone#

Persons to be called in case of emergency if unable to contact parents (may pick up child if indicated)
 Name       Phone   aaa-bbb-nnnn      Relationship
 Address     May Pick Up Child Yes No
                 Num           Street                                                                City                                                   ZipCode

 Name       Phone aaa-bbb-nnnn        Relationship
 Address     May Pick Up Child Yes No
                 Num           Street                                                                City                                                   ZipCode

Other persons authorized to pick up child from preschool
  Name            Phone aaa-bbb-nnnn      
 
 Name         Phone aaa-bbb-nnnn      
 

Electronic Signature
I hereby agree to offer my signature electronically      

Name       
Signature 
                    Please retype your name as proof of your signature

    Make all necessary entries and then click on "Submit"

 


Noah’s Ark Preschool ~ 9185 Lexington Avenue North ~ Circle Pines, MN 55014 ~ 763-784-5928