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Little Dolphins Preschool Membership Application-WAITLIST

Preschool & VPK

MEMBERSHIP APPLICATION

Unit Name:

Membership Type:

Voluntary Pre-Kindergarten (VPK) - A state funded program that provides Pre-Kindergarten to children turning 4 by September 1st.  During the school year the program runs from 9:00am to 12:00pm.

VPK with Wrap - Provides additional care from 6:30am to 9:00am and 12:00pm to 6:00pm.  The cost is $65.00 per week.

Daycare - For children 6 weeks to 5 years old (non-VPK).  Rates are based on Age.

Membership Type
Please select one membership type.

MEMBER INFORMATION

First Name
Middle Name
Last Name

MEDICAL INFORMATION

Doctor's Name and Telephone Number or N/A
Does Member have any serious medical issues? (i.e., allergies, asthma, etc.)
This list should include all known allergies
If yes, please list:

CERTIFICATIONS OF IMMUNIZATION AND HEALTH EVALUATION


PHYSICAL INFORMATION


HOUSEHOLD INFORMATION

Member Lives With...

CONTACT INFORMATION

*Primary Contact Name:
The primary contact will be the first person contacted with any concerns regarding member, member's account or in an emergency
Information/Permissions
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Select all that apply:

Information/Permissions
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Information/Permissions
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Upload Certification of Immunization
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Upload Certification of Medical Evaluation
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