2017-2018 Registration Form
For office use only
Date Registration Received:
All enrollment paperwork must be completed and submitted by
Sept. 1 to ensure your child can start preschool on the first day of class.
□ Male □ Female
Child’s Name:
Birthdate:
Home Phone:
Address:
City
State
My child has participated in Early Childhood Screening:
Zip
□ YES □ NO
Parent 1/Guardian Name: Parent 2/Guardian Name:
Address: Address:
h | w | c
Alternate Phone:
h | w | c
Alternate Phone:
Email Address:
Email Address:
Please list your preference of preschool class by location, morning/afternoon, and days of week:
First Choice:
Location:
Second Choice:
Location:
Third Choice:
Location:
□ Morning
□ Afternoon Days of Week:
□ Morning
□ Afternoon Days of Week:
□ Morning
□ Afternoon Days of Week:
Are you interested in joining the District 622 Early Childhood Advisory Council? □ Yes □ No
A $50 non-refundable registration fee is required with each registration (with the exception of Voluntary Preschool
classes.)
Check #:
Please charge $50 to:
□ Visa
□ Mastercard
□ Discover
Card #:
Exp. Date:
CVV:
Signature:
Limited financial assistance available to qualifying families. Check here to have a Financial Assistance Application mailed to the child’s
home address listed above. The form is also available online at www.isd622.org/preschool. Children age five on or before Sept. 1,
2017 are not eligible for assistance.
Early Childhood & Family Programs | Beaver Lake Center | 1060 Sterling St N, Maplewood, MN 55119
651-702-8411