St. Francis Preschool Application

Dear Parents and Guardians, We appreciate your interest in St. Francis Preschool. We look forward to collaborating with you on your child’s educational journey. Please click on Next Page to begin the application. If you have any questions or concerns, please call the Preschool Office at (808)681-0100. Sincerely, Rochelle Takata Director

Applicant Information

Student Information

School Year

Daily Attendance Plans:

Desired Start Date:

First Name

Middle Name

Last Name

Birthdate

Gender

Physical Address

Address Line 1

Address Line 2

City

ZIP Code

Mailing Address

Address Line 1

Address Line 2

City

ZIP Code

Demographic Information

The Hawaii Catholic Schools must report to the National Catholic Education Association and local agencies summary data on the gender, religion, and ethnic backgrounds of our students. Therefore, it is required that each person applying for admission to a Catholic school indicate his/her gender, religion and ethnic background on the application form. This information does not affect determination of admission. The ethnic designations are used to indicate a general group to which a person appears to belong or identifies with. Thank you for your cooperation.

Religion

Ethnic Background

Language(s) Spoken at Home

Other Language

Parent/Guardian Information

Parents Status:

Who has physical custody of applicant?

Parent/Guardian Information 1

Guardian/Parent Relationship to Minor

Opt-Out of Correspondence?

YesNo

First Name

Last Name

Home Phone

Home phone number of parent/guardian 1

Email Address

Cell Phone

Cell phone number of parent/guardian 1

Occupation/Title

Work Phone

Work phone number of parent/guardian 1

Employer

Parent/Guardian Information 2

Guardian/Parent Relationship to Minor

Opt-Out of Correspondence?

YesNo

First Name

Last Name

Home Phone

Home phone number of parent/guardian 1

Email Address

Cell Phone

Cell phone number of parent/guardian 2

Occupation/Title

Work Phone

Work phone number of parent/guardian 2

Employer

Medical Information

Applicants Primary Physician

Salutation	First Name
Last Name	Phone

Applicants Dentist

Salutation	First Name
Last Name	Phone

Medical Insurance

Applicant has health insurance?

YesNo

If Yes to to above, which type?

If Private is selected, please indicate Carrier

If Other was selected above, please provide carrier name

Does Applicant have secondary health insurance?

YesNo

If Yes to to above, which type?

If Private is selected, please indicate Carrier

If Other was selected above, please provide carrier name

Medical Conditions

Applicant receives regular care for any medical conditions?

Medical Conditions:

Please indicate all medical conditions that the preschool staff should be aware of

Allergies:

Please indicate all allergies that the preschool staff should be aware of

NOTE: Lunch & snacks are provided at our facility. Menus are posted monthly. For children who are lactose intolerant, parent must provide a milk substitute.

In case of an emergency, my child will be taken to the nearest emergency facility. I give my consent for school authorities to take appropriate action for the safety and welfare of my child.

Additional Referral and Application Information

How did you hear about St. Francis Preschool?

Name of Referral Source, if applicable:

I/We have applied to various organizations regarding tuition subsidies:

Pauahi Keiki ScholarsChild Care ConnectionPATCH Preschool Open DoorsChild Care Aware of America

Please list the names of other preschools that your child has attended:

Why did you choose St. Francis Preschool for your child?

Please share any other pertinent information about your child that would be helpful in helping to know, understand, and work with your child:

We/I certify that the information is complete and accurate. Any information found to be inaccurate might be considered grounds for dismissal from this school. I understand that all other requested documents must be received by stated due dates or as space permits in order for my child to be considered for enrollment.

Signatures

Parent/Guardian 1 Signature:	Date
Parent/Guardian 2 Signature:	Date