Noah Ark Preschool Enrollment Application
We are thrilled that you have chosen Noah's Ark Preschool for your child.
We are looking forward to getting to know you.
I want to enroll my child in:
Child's Information
Summer 2020
2020-2021 Noah's ArkPreschool Year
K-5 Grades Before/After School Care (Only Centennial District)
Child's First Name
Child's Last Name
Street Address
, MN
City
ZipCode
Child's Birthday
Year
Home Phone ###-###-####
Choose Race/Ethnic Origin
Black non-Hispanic/African American
Caucasian/White non-Hispanic
Latino/Hispanic
Hmong
Asian
Native American
Pacific Islander
African
Other
Day
Month
Select
01
02
03
04
05
06
07
08
09
10
11
12
Select
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Yes
No
Choose School District
Centennial
Anoka Hennepin (i.e. Blaine)
Mounds View
Spring Lake Park
Forest Lake
White Bear Lake
Other
Left or Right Handed
Has your chid attended pre-school screening?
What School District do you live in?
Child Gender
Male
Female
Right
Left
Do not know
What elementary school will/does your child attend?
Use an email that you monitor daily.
This will be a key way that we communicate with you.
Re-type your Email Contact
Parent/Legal Guardian Email Contact
Father
Father's First Name
Father's Last Name
Click if father lives with child
, MN
Street Address
City
ZipCode
Father's Occupation
Father's Employer
Father's WorkPhone ###-###-####
Father's Cell Phone ###-###-####
Mother
Mother's First Name
Mother's Last Name
Click if Mother lives with child
, MN
Street Address
City
ZipCode
Mother's Employer
Mother's Occupation
Mother's WorkPhone ###-###-####
Other Children in family
Yes
No
I need to create or updateother children in my family
Mother's Cell Phone ###-###-####
Birthday
Birthday
Click ON Calendar:
Select Child's Birthday
### Please Check the Year ###
Birthday
Birthday
Child 1
Child 2
Child 3
Child 4
I need to create or update my emergency contacts
Yes
No
Emergency Contacts - State of MN requires 2 contacts
Cannot be either parent !!!
Relationship
Contact may pick up child?
Yes
Select from drop down list ...
GrandMother
GrandFather
Brother
Sister
Uncle
Aunt
Friend
Other
Contact may pick up child?
Relationship
Select from drop down list ...
GrandMother
GrandFather
Brother
Sister
Uncle
Aunt
Friend
Other
No
Yes
No
Optional...Other people authorized to pick up child from preschool
Parents are automatically authorized!
Yes
No
I need to create or update my child's allergies
Allergies
Enter allergies or medical problem as appropriate
Food Allergies
Drug Allergies
Other Medical Problems
Yes
No
I need to create or update my child's medical clinics
Source of Medical Care (Clinic)
Select from drop down list ...
Other
Aalfa Family Clinic 4465 White Bear Parkway White Bear Lake MN 55110 651-653-0062
Allina Medical Clinic - Blaine 10705 Town Square Drive Ne Suite 100 Blaine MN 55449 763-236-5400
Allina Medical Clinic - Coon Rapids 9055 Springbrook Drive Coon Rapids MN 55433 763-780-9155
Allina Medical Clinic - Elk River 14181 Business Center Drive NW Elk River MN 55330 763-236-0500
Allina Medical Clinic - Forest Lake 1540 South Lake Street Forest Lake MN 55025 651-464-7100
Allina Medical Clinic - Shoreview 4194 Lexington Avenue North Shoreview MN 55126 651-483-5461
Allina Medical Clinic - Woodbury 8675 Valley Creek Road Woodbury MN 651-241-3000
Central Pediatrics - Roseville 1536 Larpenteur Avenue West St. Paul MN 55113 651-645-4693
Central Pediatrics - Woodbury 7803 Afton Road Woodbury MN 55125 651-738-0470
Fairview - Andover Clinic 13819 Hanson Blvd NW Andover MN 55432 763-572-5700
Fairview - Lino Lakes Clinic 7455 Village Drive Lino Lakes MN 55014 651-717-3400
Fairview Children's Clinic 2535 University Avenue SE Minneapolis MN 55454 612-672-2350
Fairview Clinic - Uptown 3033 Excelsior Avenue Suite 27 Minneapolis MN 55416 612-827-4751
Fairview Northeast Clinic 1151 Silver Lake Road New Brighton MN 55112 612-706-4500
Fridley Children Teenagers Medical Center 500 Osborne Road NE Suite 315 Fridley MN 55432 763-236-2700
Fridley Medical Center 480 Osborne Rd NE Fridley MN 763-785-4500
Fridley Plaza Clinic 6341 University Avenue NE Fridley MN 55432 763-572-5700
Health Partners - Arden Hills 3930 Northwoods Dr Arden Hills MN 55112 952-967-7860
Health Partners - Como Park 2500 Como Ave Saint Paul MN 55108 952-967-7955
Health Partners - Coon Rapids 11475 Robinson Drive NW Coon Rapids MN 55433 763-754-4600
Health Partners - North Suburban Family Physicians - Lino Lakes 576 Apollo Drive Lino Lakes MN 55014 651-784-1611
Health Partners - White Bear Lake 1430 Highway 96 East White Bear Lake MN 55110 651-653-2100
Healtheast - Maplewood 3100 Kennard Street Maplewood MN 55109 651-233-7800
Healtheast - Vadnais Heights 1055 Centerville Circle St. Paul MN 55127 651-326-5900
Hennepin County Medical Center Peds Bananas 716 N 7th St Minneapolis MN 55411 612-873-2300
Metro Pediatric 700 Village Center Dr Ste 110 North Oaks MN 55127 651-481-8611
Multicare Associates - Blaine Medical Center 11855 Ulysses Street NE Blaine MN 55449 763-785-4200
Multicare Associates - Fridley Medical Center 7675 Madison Street NE Fridley MN 55432 763-785-4500
Multicare Associates - Roseville 1835 West County Road C Roseville MN 55113 763-785-4500
North Clinic - Maple Grove 9825 Hospital Drive. Suite 300 Maple Grove MN 55369 763-587-7900
North Suburban Family Physicians - Lino Lakes 576 Apollo Dr Lino Lakes MN 55014 651-486-2320
Northeast Pediatric Clinic 4520 Centerville Road Vadnais Heights MN 55127 651-426-1141
Northern Lights Pediatrics - Vadnais Heights 3555 Willow Lake Boulevard Suite 140 Vadnais Heights MN 55110 651-770-2124
Northern Lights Pediatrics 14712 Victor Hugo Boulevard Hugo MN 55038 651-777-2362
Park Nicollet - Brookdale 6000 Earle Brown Drive Brooklyn Center MN 55430 952-993-4900
Partners In Pediatrics Maple Grove 12720 Bass Lake Road Maple Grove MN 55369 763-559-2861
Partners In Pediatrics Brooklyn Park 8500 Edinbrook Parkway Brooklyn Park MN 55443 763-425-1211
Pediatric And Young Adult Medicine Maplewood 1655 Beam Avenue Ste 108 Maplewood MN 55109 651-227-7806
Riverway Clinic Andover 15245 Bluebird Street NW # A Andover MN 763-712-6500
Silver Lake Clinic 1420 109th Avenue NE Suite 100 Blaine 55449 763-581-5550
Silver Lake Clinic Shoreview 4625 Churchill Street Shoreview MN 55126 651-766-3900
South Lake Pediatrics Maple Grove 12000 Elm Creek Blvd Suite 250 Maple Grove MN 55369 952-401-8300
Stillwater Medical Group 1500 Curve Crest Blvd Stillwater MN 55082 651-439-1234
Source of Dental Care (Clinic)
Select from drop down list ...
Other
No Dentist
A Gentle Dental Center - 4930 42nd Ave N Robbinsdale MN 55422 763-537-4531
Aberdeen Dental - 11800 Aberdeen Street NE Blaine MN 55449 763-786-4280
Advance Family Dentistry - Dr. Zollinger Vadnais Heights MN 651-482-1122
Andover Family Dentistry - 3480 Bunker Lake NW Blvd Suite 201 Andover MN 763-427-4780
Arden Dental - 11806 Aberdeen St NE # 150 Blaine MN 55449 763-786-1545
Armstrong Dental Office - Silver Lake Road New Brighton MN 612-788-5151
Associated Dentists - 1790 Lexington Ave N Roseville MN 55113 651-488-5557
Assure Dental - Blaine 4255 Pheasant Ridge Drive Lino Lakes MN 55014 763-225-6100
Austin Family Dental - 1360 Energy Park Dr Suite 140 St. Paul MN 55108 651-641-1908
Bates Dentistry - 2575 Hamline Ave N Suite F Roseville MN 55113 651-484-0942
Baylon Family Dentistry - 11943 Central Ave NE Blaine MN 55434 763-757-2914
Blaine Health Partners Dental Clinic - 10961 Club West Pkwy NE Suite 240 Blaine MN 763-780-1292
Children's Dental Care Specialists - 542 Snelling Ave S Saint Paul MN 651-690-2147
Circle Pines Dental - 640 Civic Heights Dr Circle Pines MN 763-786-3432
Community Dental - 1670 Beam Ave # 202 Maplewood MN 55109 651-925-8400
Dillon Dental - 1386 E Mendota Rd Inver Grove Heights MN 55077 651-451-1884
Dr. Andrew Hegstad - 20 North Lake Street Suite 311 Forest Lake MN 55025 651-464-5550
Dr. Greg S. Beinlich Dds - 9950 Valley Creek Road Woodbury MN 55125 651-702-1462
Dr. Laura Wild Dds - 2960 Snelling Ave N St. Paul MN 55113 651-636-5033
Dr. Michael Kurkowski - 3500 North Rice Street St. Paul MN 55126 651-484-5331
Dr. Nina Thai - 450 Syndicate Street N #119 St. Paul MN 55104 651-644-8882
Dr. Richard H. Barr DDS - 631 125th Ave NE Blaine MN 55434 763-757-2722
Dr. Wallace Anderson - 1260 County Road E West Arden Hills MN 651-639-0452
Droel Family Dentistry - 6776 Lake Drive Dr Suite 240 Lino Lakes MN 651-784-3583
Drs. Malone & Westman - 3920 West Broadway Robbinsdale MN 763-535-5555
Edina Dental Care - 3939 West 50th Street Suite 208 Edina MN 55424 952-922-2214
Edina Dental - 3300 Edinborough Way Suite 210 Edina MN 952-922-2214
Edlund Dental - 1021 Bandana Boulevard East #100 St. Paul MN 55108 651-645-0449
Family Dental Care - 2407 109th NE Ave Suite 240 Blaine MN 55449 763-783-8200
Family Dentistry - 500 Osborne Rd NE Fridley MN 763-786-3800
Forbes Dental - 4001 Stinson Blvd Suite 426 Minneapolis MN 55421 612-788-0751
Forest Lake Family Dental - 69 North Lake Street Forest Lake MN 55025 651-464-3484
Furey Dental Group - 700 Village Drive North Oaks MN 651-490-9011
G2 Dental - 1068 Lake St So Suite 209 Forest Lake MN 55025 651-464-2248
Garvin Dental Care - 2050 Merrimac Lane Plymouth MN 55447 763-476-4444
General And Cosmetic Dentistry - 2459 15th St NW New Brighton MN 55112 651-631-3100
Glen Oaks Dental - 2 South Pine Drive Suite M Circle Pines MN 55014 763-786-8460
Grace Dental - 12425 55th St N Lake Elmo MN 651-430-1020
HCMC Pediatric Dentistry - 701 Park Ave Minneapolis MN 612-873-2370
Health Partners - Blaine Dental Clinic 10961 Club West Pkwy NE Suite 240 Blaine MN 763-780-1292
Health Partners – Bloomington 8600 Nicollet Ave S Bloomington MN 952-541-2800
Health Partners - White Bear Lake 1430 Highway 96 E White Bear Lake MN 651-426-1980
Helping Hands Dental Clinic - 506 7th St W St. Paul MN 55102 651-224-7561
Imagine Smiles - 10705 Town Square Dr NE Suite 200 Blaine MN 55449 763-269-8650
Isaacson Gentle Dentistry - 4700 White Bear Parkway White Bear Lake MN 55110 651-762-7677
John E Ewert DDS - 1573 154th Ave NW Suite 107 Andover MN 55304 763-786-3112
Kid Grins - 14755 Victor Hugo Boulevard North Unit 103 Hugo MN 651-429-4746
Kid Grins - St. Paul Office 542 S Snelling Avenue St. Paul MN 55116 651-690-2147
Lakeview Family Dentistry - 14475 Forest Blvd N Hugo MN 55038 651-426-8088
Ling Family Dentistry - 7766 Highway 65 NE Spring Lake Park MN 55432 763-784-1993
Lino Lakes Family Dentistry - 591 Apollo Dr Circle Pines MN 651-786-7630
Manitou Dental - White Bear Lake 2189 3rd Street White Bear Lake MN 55110 651-429-9221
Maple Grove Family Dental - 12000 Elm Creek Blvd Suite 220 Maple Grove MN 55369 763-420-4421
Maplewood Community Dental - 1670 Beam Ave Maplewood MN 55109 651-925-8400
Maplewood Dental Associates - 1736 Cope Ave E Maplewood MN 55109 651-770-3831
Metro Dental Care - 4255 Pheasant Ridge Dr NE Blaine MN 55449 763-225-6100
Metro Dental Care - Blaine 261 County Road 10 NE Blaine MN 55434 763-786-9644
Metro Dental Care - Roseville 2690 Snelling Avenue N Suite 250 Roseville MN 55113 651-633-1834
Metro Pediatric Dental - North Oaks
Metropolitan Pediatric Dental - 700 Village Center Drive Suite 110 North Oaks MN 55127 651-484-8611
Metropolitan Pediatric Dental Associates Limited - 500 Osborne Rd NE # 345 Fridley MN 55432 763-786-3800
Michael Junker DDS - 6143 Osgood Ave N Stillwater MN 55082 651-439-4085
Mounds View Family Dental - 5366 Edgewood Dr Mounds View MN 55112 763-432-3399
New Brighton Dental - Dr Brian Peirce 969 Old Highway 8 NW New Brighton MN 55112 651-639-8445
North Park Dental - Blaine 9120 Baltimore St NE Blaine MN 55449 763-786-1560
Northeast Dental - 4520 Centerville Rd. White Bear Lake MN 55127 651-426-4799
Northview Dental - 4700 Lexington Avenue N Shoreview MN 55126 651-483-1858
Now Care Dental - Eagan 1380 Duckwood Drive Suite 108 Eagan MN 55123 651-686-6800
Oneka Dental - 14643 Mercantile Dr N Hugo MN 55038 651-407-0999
Park Dental - Blaine 12904 Central Ave. NE Blaine MN 55434 763-755-1330
Park Dental - Coon Rapids 9055 Springbrook Drive Suite 201 Coon Rapids MN 55433 763-786-4632
Park Dental - Maplewood 1600 Saint Johns Blvd Suite 100 Maplewood MN 55109 651-770-7585
Park Dental - Roseville 1835 County Road C West Suite 22 Roseville MN 651-636-2123
Park Dental Clinic - Coon Rapids 9055 Springbrook Drive Suite 201 Coon Rapids MN 55433 763-786-4632
Pediatric Dental Specialists - 1835 County Road Centre West St. Paul MN 55113 651-636-2123
Pediatric Dentistry - Blaine 11943 Central Avenue NE Blaine MN 55434 763-757-2914
Pediatric Dentistry – Maplewood MN
Peixin Liu DDS. - Unity Professional Building 500 Osborne Road Suite 155 Fridley MN 55432 763-786-3800
Pro Dental - 10210 Baltimore Street NE Blaine MN 763-231-2050
Quality Dentistry - 1736 Cope Avenue E St. Paul MN 55109 651-770-2951
Riverdale Pediatric Dentistry - 3585 124th Ave NW Suite #400 Coon Rapids MN 55433 763-767-1524
Roseville Pediatric - 1835 County Road C West Roseville MN 55113 651-501-0018
Round Lake Dental - 13841 Round Lake Blvd. Andover MN 55304 763-427-0285
Serene Oaks Dental - 400 Village Center Drive #100 St. Paul MN 55127 651-288-3111
Silver Lake Dental - 580 5th Avenue NW New Brighton MN 55112 651-633-6087
Smisek Family Dentistry - 501 Tanglewood Dr Shoreview MN 55126 651-483-6747
Southhill Dental – Stillwater 2850 Curve Crest Blvd Suite 200 Stillwater MN 5508 651-439-9400
St. Paul Pediatric Dentistry - 1514 White Bear Ave N St. Paul MN 5510 651-774-0311
Turry Family Dentistry - 20 Lake St N Forest Lake MN 55025 651-464-3052
Vibrant Dental - 520 West Highway 96 Suite 400 Shoreview MN 55126 651.482.7564
West Side Clinic - 478 South Robert Street St. Paul MN 55107 651-602-7575
Wyoming Family Dental - 5305 East Viking Blvd Wyoming MN 55092 651-462-5150
Source of Hospital
For emergency purposes, the closest hospital, Unity Hospital, will be used.
For non-emergencies, the parents choice below will be used.
Select from drop down list ...
Other
Amplatz Childrens Hospital 2450 Riverside Ave. Minneapolis Mn 55454 612-365-1000
Childrens Hospital 2525 Chicago Avenue South Minneapolis 612-813-6100
Childrens Hospital 345 Smith Ave N St Paul MN 651-220-6000
Fairview Lakes Regional Medical Center 5200 Fairview Blvd Wyoming Mn 55092 651-982-7000
Gillette Childrens Hospital 651-229-3800
Hennepin County Medical Center 701 Park Ave S Minneapolis MN 55415 612-873-2370
Lakeview Hospital 927 Churchill Street W. Stillwater 55082 651-439-5330
Mercy Hospital 4050 Coon Rapids Blvd. Coon Rapids Mn 55433 763-236-6000
Methodist Hospital 6500 Excelsior Blvd. St. Louis Park Mn 55426 952-993-5000
North Memorial Medical Center 3300 Oakdale Ave. N. Robbinsdale MN 55422 763-520-5200
Regions Hospital 640 Jackson Street St. Paul MN 55101 651-254-3456
St. John s Hospital 1575 Beam Avenue Maplewood 651-232-7000
United Hospital 333 North Smith Avenue St. Paul MN 55102 651-241-8000
Unity Hospital 550 Osborne Road Fridley 55432 763-236-5000
University of Minnesota Medical Center 2450 Riverside Ave. 612-273-3000
Woodwinds 1925 Woodwinds Dr Woodbury MN 651-232-0228
Language Spoken at Home
Yes
No
Months
Age at adoption
Yes
No
Child's Emotional Behavior
Is s/he
OK to select more than one
Is s/he
OK to select more than one
Does Child Know?
Yes
No
Yes
No
Yes
No
shy
friendly
cautious
outgoing
calm
excitable
easily angered
whiny
cries easily
happy
cooperative
quiet
independent
active
dependent
wants own way
temper tantrums
stuborn
Other
None
Looking for a church
Abiding Savior - Mounds View
Abundant Life - Blaine
Bridgewood Community - Blaine
Calvary - White Bear
Church Of St. Paul - Ham Lake
Concordia Lutheran - South St Paul
Cornerstone Church - Blaine
Corpus Christi - Roseville
Eagle Brook - Blaine
Eagle Brook - Coon Rapids
Eagle Brook - Lino Lakes
Eagle Brook - Spring lake Park
Emmanuel Christian Center - Fridley
Epiphany Catholic Church - Coon Rapids
Glen Cary - Ham Lake
Good Shephard Lutheran - Circle Pines
Gracepoint Baptist - New Brighton
Horizons Community Church - Ham Lake
Incarnation Lutheran - Shoreview
North Heights - New Brighton
Our Saviors Lutheran - Circle Pines
Peace Lutheran - Coon Rapids
Peace United Methodist
Redeemer Lutheran - Coon Rapids
Seventh Day Adventist
Shepherd Of The Hills - Shoreview
St. Bernards Catholic - St. Paul
St. Genevieve Catholic - Centerville
St. Gerard's Catholic - Brooklyn Park
St. John The Baptist Catholic - New Brighton
St. Joseph's Catholic - Lino Lakes
St. Mark's Lutheran - Circle Pines
St. Mary's Of The Lake - White Bear Lake
St. Olaf Lutheran - Minneapolis
St. Phillip's Lutheran - Fridley
St. Timothy's Catholic - Spring Lake Park
Yes
No
Other
None
Looking for a church
Abiding Savior - Mounds View
Abundant Life - Blaine
Bridgewood Community - Blaine
Calvary - White Bear
Church Of St. Paul - Ham Lake
Concordia Lutheran - South St Paul
Cornerstone Church - Blaine
Corpus Christi - Roseville
Eagle Brook - Blaine
Eagle Brook - Coon Rapids
Eagle Brook - Lino Lakes
Eagle Brook - Spring lake Park
Emmanuel Christian Center - Fridley
Epiphany Catholic Church - Coon Rapids
Glen Cary - Ham Lake
Good Shephard Lutheran - Circle Pines
Gracepoint Baptist - New Brighton
Horizons Community Church - Ham Lake
Incarnation Lutheran - Shoreview
North Heights - New Brighton
Our Saviors Lutheran - Circle Pines
Peace Lutheran - Coon Rapids
Peace United Methodist
Redeemer Lutheran - Coon Rapids
Seventh Day Adventist
Shepherd Of The Hills - Shoreview
St. Bernards Catholic - St. Paul
St. Genevieve Catholic - Centerville
St. Gerard's Catholic - Brooklyn Park
St. John The Baptist Catholic - New Brighton
St. Joseph's Catholic - Lino Lakes
St. Mark's Lutheran - Circle Pines
St. Mary's Of The Lake - White Bear Lake
St. Olaf Lutheran - Minneapolis
St. Phillip's Lutheran - Fridley
St. Timothy's Catholic - Spring Lake Pa
Yes
No
Yes
No
Is Child Adopted?
Please list above some of your child's favorite play activities and interests
Are there any persons other than parents and siblings in the home?
Are there any cultural or religious customs that you would like to share with us?
Day Care
Day Care Phone ###-###-####
Day Care Provider Name
Social Development
Has child had previous group experience?
If yes, where?
Does s/he get along well with other children?
What do you expect for your child at preschool?
Religious Information
Child attends Sunday School?
If other
Name of church MOTHER atttends
Mother active?
If other
Name of church FATHER atttends
Enrollment in the Summer 2020
Select Full Day classes
Full Day Classes (9AM to 3:30PM)*
MTWRF
MWF
TWTh
MF
TTh
Choose Your Days =>
5 Days
3 Days
2 Days
2 Days
3 Days
1 to 4 Days
Monday
Tuesday
Wednesday
Thursday
Friday
* Add Before Care and/or After Care
Before Care
After Care
No BC
Pickup before 4:30PM
No AC
Arrive before 9AM after 8AM
Or, Select Half Day classes
Half Day AM Classes - 9:00AM to 12:00PM
Choose Your Days =>
TTh
MF
TWTh
MWF
MTWRF
5 Days
3 Days
2 Days
1 to 4 Days
2 Days
3 Days
Monday
Tuesday
Wednesday
Thursday
Friday
MTWRF
MWF
TWTh
MF
TTh
Choose Your Days =>
Enrollment in the 2020-2021 Preschool Year
Select Full Day classes
Full Day Classes (9AM to 3:30PM)*
1 to 4 Days
5 Days
2 Days
3 Days
2 Days
3 Days
Monday
Tuesday
Wednesday
Thursday
Friday
* Add Before Care and/or After Care
After Care
Before Care
No BC
No AC
Pickup before 4:30PM, or
Arrive before 9AM
Pickup before 5:30PM
Arrive before 8AM
Or, Select Half Day classes
Half Day AM Classes - 9:30AM to 1:00PM Includes lunch
MTWRF
MWF
TWTh
MF
TTh
Choose Your Days =>
1 to 4 Days
2 Days
3 Days
5 Days
3 Days
2 Days
Monday
Tuesday
Wednesday
Thursday
Friday
Enrollment in the Centennial District Before School and/ or After School
Centennial District provides bus transportation to or from your child's school
Not available for Centerville Elementary
Before School Care
After School Care
and/or
Pickup before 4:30PM, or
Pickup before 5:30PM
No AC
Arrive after 8AM
Arrive between 7AM and 8AM
No BC
Enter First Name and Last Name
Re-enter First Name and Last Name
Enter any special instructions like have Director contact me, etc.
Date
Father active?