James Hubert Blake High School Lab Preschool
300 Norwood Road
Silver Spring, MD 20905
Phone 301 879-1337 Fax: 301 879-1306
Application Form 2015-2016 School Year
OFFICE USE ONLY
Application date: _______
Deposit: ______date:____
Fall balance: __________
Spring balance: ________
Directions: Complete the application below. When your child is accepted, you will be required
to complete the forms listed below:
 Health Inventory
 Immunization Record
 Emergency Contact Card
Please return this application with non-refundable registration fee (payable to Blake High
School). $300 will be due in October. Yearly tuition is $600. If you have any questions, please
feel free to call Beth Kauffman (301) 879-1337
Child’s Name: _________________________________________________________________
Last
First
Middle
Child prefers to be called: _____________________________________ Gender: ___________
Date of Birth: _____________
Age as of September 2015*: ___ Years _____Months
Address: ______________________________________________________________________
Street
City
State
Zip code
Home Phone _____________________________ Email: ________________@_____________
Neighborhood School: ____________________
FAMILY INFORMATION
Father’s/Guardian’s Name:________________________________________________________
Work Phone: _______________________________ Cell Phone: _________________________
E-mail: _______________________________________________________________________
Father’s occupation and educational background:______________________________________
Mother’s/Guardian’s Name: ______________________________________________________
Mother’s occupation and educational background:_____________________________________
Address: (if different) ___________________________________________________________
Work Phone: _______________________ Cell Phone: _________________________________
Child lives with Mother: ____ Father: ____ Both: ____ Other: ___
Family Members or Others Living in the Home:
Siblings:
Name
________________________________
________________________________
________________________________
________________________________
________________________________
6/16/2015
Relationship (include children’s ages)
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Is English the first language spoken in the home? Yes: ___ No: ___
If no, what is the first language spoken in the home? ___________________________________
Ethnic or cultural background: _____________________________________________________
Holidays celebrated: _____________________________________________________________
My child plays with (describe play with other children in the neighborhood, relatives, etc.): ____
______________________________________________________________________________
______________________________________________________________________________
Has your child had previous experience in group childcare or preschool? Yes: ___ No: ___
If yes, please describe: ___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
My child learns best when: _______________________________________________________
______________________________________________________________________________
My child enjoys or is interested in: _________________________________________________
______________________________________________________________________________
My child does not like or avoids: ___________________________________________________
______________________________________________________________________________
Special health problems: _________________________________________________________
Dietary restrictions or allergies*: __________________________________________________
*EpiPen for severe allergies of any kind- please let us know.
Current height is_____ Weight is:_______
IN CASE OF EMERGENCY:
Name: ________________________________________Phone:________________________
Doctor’s name:_________________________________ Phone:________________________
Hospital preference: ___________________________________
My child does/ does not (circle one) have either an Individual Family Service Plan (IFSP) or an
Individual Education Plan (IEP).
I would describe my child in this way: ______________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________