Preschool Application
Preschool Application Applicant’s name (Last)
(First)
(Middle)
Date of Birth
Social Security Number
Male
Female
Address (Street)
(Apt.)
(City)
(State)
Telephone#
(Zip)
Cell#
Applicant is interested in attending for the following semester: Fall
Summer
Have You Attended a School Tour? __________
When? __________
ADMISSIONS PROCEDURE 1. Return the completed application form and a recent photograph to the School for Language and Communication Development. 2. Forward copies of the current IEP (Individualized Educational Plan), and all Educational, Psychological, Speech/Language and other relevant evaluation reports to the School for Language and Communication Development. 3. If you are interested in touring our facilities, contact our office at: (516) 609-2000, ext. 112. SLCD admits students of any race, religion, national and ethnic origin. It does not discriminate on the basis of race, religion, national and ethnic origin, or sexual orientation in the administration of its educational policies & admissions policies.
Signature of Parent
Date
Father's Name Address (if different from page 1) Email Address:_________________ Occupation and Title Employer/Business Address Telephone# College(s) attended
Degree/Date
Secondary School
Degree/Date
Mother's Name Address (if different from page 1) Email Address:_________________ Occupation and Title Employer/Business Address Telephone# College(s) attended
Degree/Date
Secondary School
Degree/Date
Please check all that apply: ________ Father or Mother deceased ________ Single
Separated child is adopted
Divorced
If parents are separated or divorced: a) Who is the child's legal guardian? b) To whom should correspondence be sent? Child lives with (check all that apply): ________ Father ________ Other-Relationship
Mother
Stepfather
Stepmother
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Names of Brothers and Sisters
Age
Present school/grade/occupation
If there are other members of the household in addition to parents and children, what is their relationship to the applicant? Primary language of the child Primary language spoken in the home Name and Address of applicant's present school
Applicant's School District School District Contact Person Telephone# Has your child been enrolled in a preschool program? If yes, where and when did he/she attend? Describe your child's school experience Has your child been evaluated by the Early Intervention Program? If yes, When
Does your child receive Early Intervention Services? If yes, please describe which services and frequency.
Yes
No
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Please check all that apply: Has your child been under the care of or received any of the following professional evaluations? Please indicate the date of the evaluation. Audiologist
Psychologist
Speech/Language Pathologist
Occupational Therapist
Otolaryngologist (ENT)
Physical Therapist
Neurologist
Psychiatrist
Neuropsychologist
Opthamologist
Other Why was your child seen?
Please check the appropriate column which may apply to your child: Yes 1. 2. 3. 4. 5. 6. 7. 8. 9.
Anemia Allergies Asthma Fainting Epilepsy Convulsions Migraine Headaches Heart Problems Kidney Problems
No
Yes 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
No
Endocrine/hormonal Hyperactivity Sleeping Problems Vision Problems Wears Glasses Hearing Problems Uses Hearing Device Physical Problems Uses Orthopedic Device Other
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Current medications used and dosage
How long has your child used this medication? Does your child have any limitations or health problem of which the school should be aware?
What do you believe are your child's greatest strengths?
What do you believe are your child's greatest challenges?
Who referred you to the School for Language and Communication Development?
Please comment briefly on your reasons for wanting your child to attend the School for Language and Communication Development.
Please Initial : This allows SLCD to send future emails concerning our school._____
p.5
(First)
(Middle)
Date of Birth
Social Security Number
Male
Female
Address (Street)
(Apt.)
(City)
(State)
Telephone#
(Zip)
Cell#
Applicant is interested in attending for the following semester: Fall
Summer
Have You Attended a School Tour? __________
When? __________
ADMISSIONS PROCEDURE 1. Return the completed application form and a recent photograph to the School for Language and Communication Development. 2. Forward copies of the current IEP (Individualized Educational Plan), and all Educational, Psychological, Speech/Language and other relevant evaluation reports to the School for Language and Communication Development. 3. If you are interested in touring our facilities, contact our office at: (516) 609-2000, ext. 112. SLCD admits students of any race, religion, national and ethnic origin. It does not discriminate on the basis of race, religion, national and ethnic origin, or sexual orientation in the administration of its educational policies & admissions policies.
Signature of Parent
Date
Father's Name Address (if different from page 1) Email Address:_________________ Occupation and Title Employer/Business Address Telephone# College(s) attended
Degree/Date
Secondary School
Degree/Date
Mother's Name Address (if different from page 1) Email Address:_________________ Occupation and Title Employer/Business Address Telephone# College(s) attended
Degree/Date
Secondary School
Degree/Date
Please check all that apply: ________ Father or Mother deceased ________ Single
Separated child is adopted
Divorced
If parents are separated or divorced: a) Who is the child's legal guardian? b) To whom should correspondence be sent? Child lives with (check all that apply): ________ Father ________ Other-Relationship
Mother
Stepfather
Stepmother
p.2
Names of Brothers and Sisters
Age
Present school/grade/occupation
If there are other members of the household in addition to parents and children, what is their relationship to the applicant? Primary language of the child Primary language spoken in the home Name and Address of applicant's present school
Applicant's School District School District Contact Person Telephone# Has your child been enrolled in a preschool program? If yes, where and when did he/she attend? Describe your child's school experience Has your child been evaluated by the Early Intervention Program? If yes, When
Does your child receive Early Intervention Services? If yes, please describe which services and frequency.
Yes
No
p.3
Please check all that apply: Has your child been under the care of or received any of the following professional evaluations? Please indicate the date of the evaluation. Audiologist
Psychologist
Speech/Language Pathologist
Occupational Therapist
Otolaryngologist (ENT)
Physical Therapist
Neurologist
Psychiatrist
Neuropsychologist
Opthamologist
Other Why was your child seen?
Please check the appropriate column which may apply to your child: Yes 1. 2. 3. 4. 5. 6. 7. 8. 9.
Anemia Allergies Asthma Fainting Epilepsy Convulsions Migraine Headaches Heart Problems Kidney Problems
No
Yes 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
No
Endocrine/hormonal Hyperactivity Sleeping Problems Vision Problems Wears Glasses Hearing Problems Uses Hearing Device Physical Problems Uses Orthopedic Device Other
p.4
Current medications used and dosage
How long has your child used this medication? Does your child have any limitations or health problem of which the school should be aware?
What do you believe are your child's greatest strengths?
What do you believe are your child's greatest challenges?
Who referred you to the School for Language and Communication Development?
Please comment briefly on your reasons for wanting your child to attend the School for Language and Communication Development.
Please Initial : This allows SLCD to send future emails concerning our school._____
p.5
