VHCS PRESCHOOL PROGRAMPeer Model Application

VHCS PRESCHOOL PROGRAM

Peer Model Application

Child's Legal Name*

Full Name (First, Middle, Last)

Date of Application*

Date of Birth*

Gender*

Select

Address*

Physical Address (Street, City, State, & Zip)

Parent/Guardian #1

Parent/Guardian 1 Name*

Full Name

Parent/Guardian 1 Contact Number*

Phone

Parent/Guardian 1 Email*

Parent/Guardian #2

Parent/Guardian 2 Name

Parent/Contact 2 Contact Number

Phone

Parent/Guardian 2 Email

Does your child have a sibling currently enrolled in VHCS?*

Select

if Yes, please list sibling/s name, grade, and school they attend

Has your child attended a preschool program?*

Select

if Yes, please list name of preschool and dates of attendance

My child's strengths are*

My child's weaknesses are*

What behavior strategies are used at home?*

How would you describe your child's personality?*

What activities does your child enjoy?*

Is there any additional information you would like us to know about your child when considering this application?

(For example fears, allergies, medications, habits, needs, etc.)

Please answer the following questions about your child using Yes, No, or Sometimes

Is your child...

Fully potty-trained, using the restroom independently?*

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Able to feed self independently using a fork/spoon?*

Select

Able to drink from an open cup?*

Select

Able to verbally respond to simple "WH" questions?*

("WH" words: Who, Where, When, Why)

Select

Able to take turns with minimal assistance?*

Select

Speaking in short phrases and sentences?*

Select

Able to follow 2-3 Step directions?*

Select

Able to cooperatively work with peers?*

Select

Willing to help with simple tasks when asked?*

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Able to speak clearly and understood by unfamiliar listeners?*

Select

Able to separate easily from parents without crying?*

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Able to dress independently?*

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Able to follow rules and routines?*

Select

VHCS preschool program classrooms are housed in three (3) of our elementary schools. Please select your preferred location. While your request will be considered, please note that it is not a guaranteed placement if your child is accepted to our program.*

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There is a non-refundable registration fee of $100.00 due prior to your application being considered. Your child's acceptance into the program will depend on information taken from a developmental screener, observations, a family interview, and the number of open slots available in the classrooms. Please sign your name below.*

(Name of parent completing the application)

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