PreK - 1st Grade Application Click here for the 2nd - 12th Grade Application 123456 Student InformationStudent Name* First Middle Last NicknameTo be used at school by peers & teachers Address* Street Address City State / Province / Region ZIP / Postal Code Primary Telephone*Can the phone number listed above receive SMS messages (text)?*YesNoDate of Birth* Month Day Year Male or Female?* Male Female Is your child a U.S. citizen?* Yes No Applying for:* Preschool T/Th Preschool M/W/F Kindergarten 1st Grade Family InformationWith whom does the applicant reside?* Are there special child custody provisions?*If yes, please provide documentation. Yes No Child Custody Documentation*Accepted file types: pdf, doc, docx, Max. file size: 300 MB.Father/Male GuardianName* First Last Email* Primary Phone*Secondary PhoneCan the Primary Phone number listed above receive SMS messages (text)?*YesNoHome Address* Street Address City State / Province / Region ZIP / Postal Code Marital Status* Spouse Living at Home Separated Divorced Spouse Deceased Employer* Employer Address* Street Address City State / Province / Region ZIP / Postal Code Mother/Female GuardianName* First Last Email* Primary Phone*Secondary PhoneCan the Primary Phone number listed above receive SMS messages (text)?*YesNoHome Address* Street Address City State / Province / Region ZIP / Postal Code Marital Status* Spouse Living at Home Separated Divorced Spouse Deceased Employer* Employer Address* Street Address City State / Province / Region ZIP / Postal Code Are there siblings in the home?* Yes No What are their names and ages?* Financial InformationAre you interested in applying for financial assistance (K and up)?* Yes No Financial obligation for tuitions & fees goes to:* Father Only Both Parents Mother Only If someone other than the parent/guardian listed above is responsible for the financial obligations while this student is enrolled at Mount Zion, please complete the following information:Name First Last Relationship to Student Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneEmail Address Education & HistoryPlease list all schools the applicant previously attended starting with the most recent if applicable:*Name of SchoolCity/StatePhone NumberGrade(s) Add RemovePotty-Training*Check any and all that apply. Use space provided to elaborate, as needed. My child is fully potty trained (see specific list below)Successfully takes care of all bathroom needs.Wipes, dresses, flushes and washes hands independently.Realizes need to use bathroom without prompting.Accidents are rare, but when it happens can change without assistance. Does not have accidents at naptime. My child is in the process of potty training (see specific list below)May need help with taking care of bathroom needs.May need moral support while taking care of bathroom needs.Reminders to wipe, flush and wash. Some assistance to dress.Needs reminders to use the bathroom.Still has accidents during the day or during nap. May need assistance after an accident. My child will be working on this over the summer, so he or she will be ready in the fall. I understand that this means that my child will be conditionally accepted. Potty-Training Additional CommentsDoes the applicant have pottying needs or aids?*ie: pull-ups, needs assistance, etc. Yes No If yes, explain:* Has the applicant ever received public or private services for an identified learning disability?* Yes No Please explain:* Are there any medical diagnoses that could impact his or her success in a classroom environment?* Yes No If yes, explain:* Does the applicant have any history of health problems (physical or emotional)?* Yes No If yes, explain:* Is the applicant on medication?* Yes No If yes, type(s)* If yes, what is the intended result(s) of the medication(s)?* Does the applicant have any type of learning disability, difficulty or limitations?* Yes No If yes, explain:* Is the applicant currently involved in any special programs or receiving any special services from your school or from a private source?* Speech Therapy Physical Therapy Occupational Therapy None Other If other, explain:* If so, please provide documentation of testing, which was done to qualify the applicant.Accepted file types: pdf, doc, docx, Max. file size: 300 MB. At Mount Zion Christian Schools, we love our students and their families. Please take a few minutes to give us some parental insight to help us get to know your child even better.What are your child’s favorite activities?*What is your child looking forward to most about school?*What are your goals/desires for your child this year in school?*Does your child have trouble transitioning away from you?* My child easily transitions to another caregiver. My child is reluctant to leave parent. My child has a difficult time separating. My child has not had experience separating from parents. Other If other, explain:* If they do have trouble separating , what have you found to be helpful? Behavior observationsCheck all that apply. Use space provided to elaborate, if needed. Has temper tantrums Can be shy Sensitive to noise or other stimuli Other If other, explain:* Behavior observations commentsSocial play observations*Check all that apply. Use space provided to elaborate, if needed. Trouble sharing/ Cooperating with peers Tends to observe play of peers Tends to play side by side with peers Tends to play interactively with peers Does not typically play with peers Social play observations commentsHealth Concerns, allergies etc. Has food or product allergies Other allergies or sensitivities Precautions (things you would like us to consider or be aware of) Pertinent Medical History of Child (premature birth, speech or developmental delays, previous or current medical conditions, early intervention etc.) Health concerns additional comments*Bed time* Hours : Minutes AM PM AM/PM Wake time* Hours : Minutes AM PM AM/PM Naps* My child takes a nap every day. My child takes a nap most days. My child rarely or never takes a nap If yes, what times?* Parent InformationIs there anything you would like to share about your child with his or her prospective teacher?Please write a paragraph or two to describe why you would like your son/daughter to attend Mount Zion Christian Schools:*How did you hear about Mount Zion Christian Schools?* Consent* I have completed this student application truthfully, to the best of my knowledge and give permission for Mount Zion Christian Schools’ administration to call past and current teachers.Consent* I understand Mount Zion is a Christian preschool, kindergarten, and 1st grade. Further, I understand that in order to enroll in Mount Zion’s Elementary program and beyond I will need to sign their Statement of Faith.Consent* I understand that all preschool enrollments are “conditional” based on my child’s demonstrated ability to meet pottying requirements as listed above.Father/Guardian Signature Date Month Day Year Mother/Guardian Signature Date Month Day Year Δ
