Waiting list 

 NAME OF CHILD:  _____________________________________________________________________________________________________________________   DATE OF BIRTH :  _______________________________________________________________ GENDER      □ M □ F  M / D / Y  NAME OF SCHOOL/PRE­SCHOOL/DAYCARE TRANSFERRING FROM:  __________________________________________________________________   REASON FOR TRANSFER:  __________________________________________________________________________________________________________  DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD’S DEVELOPMENT?   □ YES □ NO   

□ Hearing    □ Vision         □ Language     □ Gross Motor         □ Fine Motor               □ Social   □ Autism     □ Aspergers   □ ADD             □ ADHD                   □ Behavior Disorder   □  Down syndrome □ Anxiety    □ Obsessive Compulsive        □ Selective Mutism  □ Other   _________________________________________________________________________________________________________________________ (SPECIFY)   DOES YOUR CHILD HAVE ANY DEVELOPMENTAL DELAYS ? □ Yes  □  No   ___________________________________  DOES YOUR CHILD HAVE ANY PHYSICAL PROBLEMS ? □ Yes  □  No  ________________________________________   NAME OF FATHER:  _________________________________________________________________________________________________________________   OCCUPATION FATHER:  _____________________________________________________________________________________________________________   PHONE #   HM:   _________________________________________________ WK:   ______________________________________________________________

   CELL:   ________________________________________________   E­Mail Address: ___________________________________________________________________________________________________________________    NAME OF MOTHER: _________________________________________________________________________________________________________________   OCCUPATION OF MOTHER: __________________________________________________________________________________________________________   PHONE #   HM:   __________________________________________________ WK:   ______________________________________________________________

  CELL:   _______________________________________________    E­Mail Address: ____________________________________________________________________________________________________________________   Date: ________________________________________ Signature: _____________________________________________________________________ 

    ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­            FOR OFFICIAL USE ONLY  SCHOOL YEAR:                                                                CLASS:   _______________________________                             __________________________________        _______________________________                          ____________________________________  Children transferring in classes Infant II to Standard VI must attach copies of recent and previous year’s Report Cards.