Step 1 of 3 33% Preschool Registration FormTo begin, register for Preschool by either calling our office: 712-258-5137 or by filling out this form. Please note, in addition to this online form, several other paper documents are required and can be submitted at the end of this form. *Please note, this form is only required if your child is four (4) years of age and reside in Iowa.Child's Name(Required) First Last Does your child have a nickname? If so, please enter it below. Child's Date of Birth(Required) MM slash DD slash YYYY Child's Gender(Required)FemaleMalePrefer not to answerName of Parent/Guardian #1(Required) First Last Phone Number(Required)Email Address(Required) Name of Parent/Guardian #2(Required) First Last Phone Number(Required)Email Address(Required) Home Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Country(ies) Family is From(Required) Please enter to County and City/Region Parent/Guardian #1 and Parent/Guardian #2 are from.Primary Language(s) Spoken at Home(Required) Please list all languages spoken where the child is raised.Family Income (for scholarship information)(Required) $0 up to $9,999 $10,000 up to $24,999 $25,000 up to $49,999 $50,000 to to $74,999 $75,000 and up Prefer not to answer How many members are in the household?Please enter a number from 1 to 25.Is the family at risk for homelessness?(Required) Yes No Can your child independently use the bathroom?(Required) Yes No If no, please explain: Are there any developmental concerns we should be aware of?(Required) Hearing Visual Physical Emotional Developmental There are no concerns Please elaborate: Please circle the Preschool option you'd like your child to attend:(Required) Half Day (8:15-12:15PM) Full Day (8:15-3PM) Photography(Required) Yes No I give permission to Mary J. Treglia Community House and its employees and volunteers to take pictures of my children and can be used for publications or in advertising.Accidents/Injury Waiver(Required) By checking this box, I agree to this waiver.I waive and release all rights and claims against Mary J. Treglia Community House and all of its agents for any accidents/injury my child may suffer in or around Mary J. Treglia Community House.Accurate Information(Required) By checking this box, I agree to this waiver.I certify that all the information given on this form is correct to the best of my knowledge. I promise to notify Mary J. Treglia Community House if any information changes.Your Comments/Questions
