St. Thomas’s Community Preschool

119 Caroline Street

PO Box 147

Orange, VA 22960

540-672-2337

Application for School Year _____

M/W/F Program ____ for four- and five-year-olds. Must be four by Oct. 1, 20____.

TU/TH Program ____ for three-and four-year-olds. Must be three by Oct. 1, 20____.

Check which Program above. Tuition Assistance application enclosed? ___yes ___no

Child’s name__________________________________ Date of birth________________

Address_______________________________________________________ Sex______

Family email address__________________________________________

Previous school experience__________________________________________________

Mother’s name ________________________ Place of business_____________________

Business phone ______________________

Address_________________________________________________________________

Home phone________________________ Mobile phone _________________________

Father’s name _________________________ Place of business_____________________

Business phone ______________________

Address_________________________________________________________________

Home phone__________________________ Mobile phone _______________________

Person(s) having legal custody of child________________________________________

Siblings’ names and ages___________________________________________________

Medical Information

Food allergies ___________________________________________________________

Drink allergies___________________________________________________________

Drug allergies____________________________________________________________

Other___________________________________________________________________

Health problems__________________________________________________________

Child’s physician____________________________________________ Phone______________

Child’s dentist______________________________________________ Phone______________

Medications____________________________________________________________________

Emergency contact (other than parent)___________________________ Phone______________

Pick-up adults (other than parents)______________________________ Phone______________

__________________________________________________________ Phone______________

Parents’ signatures____________________________________________ Date______________

__________________________________________________________ Date_______________

Please return this application with a nonrefundable application fee of $35 made payable to:

St. Thomas’s Community Preschool

P. O. Box 147,

Orange, VA 22960

St. Thomas’s Community Preschool does not discriminate on the basis of race, color, or national ethnic origin of its students