SMILE PRESCHOOL AND NURSERY APPLICATION
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Last Name
Address
Street Address
Street Address Line 2
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Nigeria
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Northern Mariana
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Saint Barthelemy
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Samoa
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Saudi Arabia
Senegal
Serbia
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Singapore
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Solomon Islands
Somalia
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South Africa
South Ossetia
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Sri Lanka
Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
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Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
E-mail
CHILD NAME
First Name
Last Name
Birth Date
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1925
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1921
1920
Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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NICKNAME
First Name
Last Name
MOM NAME
First Name
Last Name
DAD NAME
First Name
Last Name
MOM HOME PHONE
-
Area Code
Phone Number
MOM WORK PHONE
-
Area Code
Phone Number
MOM CELL PHONE
-
Area Code
Phone Number
DAD HOME PHONE
-
Area Code
Phone Number
DAD WORK PHONE
-
Area Code
Phone Number
DAD CELL PHONE
-
Area Code
Phone Number
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EMERGENCY CONTACT PERSON
First Name
Last Name
Phone Number
-
Area Code
Phone Number
EMERGENCY CONTACT PERSON 2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
DO YOU HAVE A BACK UP CARE PROVIDER?
YES
NO
ENROLLMENT DATE
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January
February
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Month
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10
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22
23
24
25
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29
30
31
Day
Please select a year
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2021
2020
2019
2018
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2016
2015
2014
2013
2012
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2010
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2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
HOURS: MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
DROP OFF TIME
PICK UP TIME
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YOUR CHILD'S HEALTH
Child's health record: A copy of your child's immunizations and current physical will be needed.
GENERAL STATEMENT OF HEALTH
DOCTOR'S NAME
First Name
Last Name
Phone Number
-
Area Code
Phone Number
DENTIST NAME
First Name
Last Name
Phone Number
-
Area Code
Phone Number
IS YOUR CHILD'S IMMUNIZATIONS UP TO DATE?
YES
NO
PLEASE UPLOAD A SCANNED SIGNED COPY OF YOUR CHILD'S IMMUNIZATION RECORD
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DOES YOUR CHILD HAVE ALLERGIES?
YES
NO
UNKNOWN
DO YOU THINK YOUR CHILD MAY HAVE ALLERGIES TO ANYTHING? IF SO, PLEASE NAME WHAT IT IS.
DOES YOUR CHILD HAVE ANY MEDICAL CONDITIONS THAT WE SHOULD BE AWARE OF?
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DOES OR HAS YOUR CHILD HAD/HAVE THE FOLLOWING COMMON CHILDHOOD ILLNESSES? [CHECK ALL THAT APPLY]
CONSTIPATION
CONVULSIONS
DIARRHEA
FAINTING SPELLS
FREQUENT COLDS
FREQUENT EAR INFECTIONS
FREQUENT SORE THROATS
LICE
RINGWORM
SKIN RASH
SOILING
STOMACH UPSETS
URINARY PROBLEM
WORMS
ASTHMA
BRONCHITIS
CHICKEN POX
DIABETES
HEART DISEASE
HEPATITIS
IMPETIGO
MEASLES
MUMPS
GERMAN MEASLES
POLIO
SCARLET FEVER
TUBERCULOSIS
WHOOPING COUGH
DOES YOUR CHILD HAVE ANY SPEECH, HEARING, OR VISUAL PROBLEMS? IF SO, PLEASE TELL US HERE AND GIVE DETAILS ABOUT IT.
WOULD THERE BE ANY RESTRICTIONS TO PLAY OR ACTIVITIES?
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ABOUT YOUR CHILD
HAS YOUR CHILD EVER BEEN IN CHILD CARE BEFORE?
YES
NO
WHAT TYPE?
CENTER
FAMILY DAYCARE
RELATIVE
HOME DAYCARE
OTHER
IF "OTHER" - WHAT TYPE?
WHAT IS YOUR NORMAL METHOD OF DISCIPLINE?
ARE THERE ANY FOOD RESTRICTIONS? IF SO, WHAT?
WHAT IS YOUR CHILD'S FAVORITE FOOD?
WHAT FOOD(S) DOES YOUR CHILD DISLIKE?
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WILL YOUR CHILD BE RELIED UPON TO INDICATE BATHROOM WISHES? PLEASE EXPLAIN IN DETAIL.
WHAT WORDS DOES YOUR CHILD USE FOR BOWEL MOVEMENTS AND URINATION?
HAS YOUR CHILD HAD EXPERIENCE PLAYING WITH OTHER CHILDREN?
YES
NO
WHAT LANGUAGES ARE SPOKEN AT YOUR HOME?
DOES YOUR CHILD HAVE ANY SECURITY OBJECTS SUCH AS BLANKETS, SOOTHER, BOTTLE, TOY, ETC? IF SO, PLEASE TELL US.
ARE THERE ANY OTHER COMMENTS OR INFORMATION YOU WOULD LIKE TO LET US KNOW ABOUT YOUR CHILD?
ARE THERE ANY SPECIFIC CONCERNS WE NEED TO KNOW?
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