BROADWAY PRESBYTERIAN CHURCH NURSERY SCHOOL
601 W. 114th Street
New York, NY 10025
(212) 864-6100, ext. 130
2016-2017 Application for Enrollment in 4s and Nearly 4s Class
(Child will be 3 years, 6 mos – 4 years, 9 mos by Sept. 2016)
Please submit no later than January 4, 2016
Full Name of Applicant: _________________________________________________________
(First)
(Middle)
(Last)
Name usually called: __________________ Date of birth___________ □ Male □ Female
Home address: _________________________________________________________________
Preferred telephone: ____________________ Language(s) spoken at home: ________________
4s and Nearly 4s Class, M-F
□ Morning Session (9:00-12:30)
□ Extended Day (9:00-2:30)
Applying for:
If early school drop off at 8:00 am were available
for a fee, would you sign up for this service?
□ Yes □ No
Name, address and dates of schools or groups previously attended:
______________________________________________________________________________
______________________________________________________________________________
May we contact these schools for their evaluation of your child? □ Yes □ No
If no, please state reason: _________________________________________________________
The applicant’s parent(s) is/are: □ living together
□ single parent
□ separated
□divorced
deceased: □ mother □ father
With whom does the child live? ____________________________________________________
Parent/Guardian 1 Name: _________________________________________________________
Home address: _____________________________________Telephone:___________________
Business/Profession: _________________________________Telephone:__________________
Business Address: ______________________________________________________________
Email address: _________________________________________________________________
Parent/Guardian 2 Name: _________________________________________________________
Home address: _____________________________________Telephone:___________________
Business/Profession: _________________________________Telephone:__________________
Business Address: ______________________________________________________________
Email Address: _________________________________________________________________
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Applicant Name: ________________________
Siblings and/or step-siblings:
Name: ________________________Age:__________School:____________________________
Name: ________________________Age:__________School:____________________________
Name: ________________________Age:__________School:____________________________
What is the applicant’s present state of health? ________________________________________
List any significant illnesses and/or allergies: _________________________________________
______________________________________________________________________________
Is applicant under any medical treatment at present? □ Yes □ No
If yes, please describe: ___________________________________________________________
______________________________________________________________________________
It is our wish to know your child as fully as possible. To this end we urge you to answer the
following sections openly.
What are your child’s most pronounced interests and abilities? ___________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What areas are of concern to you? __________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please tell us about any event in your child’s life of profound influence: ____________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Applicant Name: ________________________
Has your child received Early Intervention or related services (OT, Speech etc.)?
□ Yes □ No
If yes, please describe candidly: ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What is it that draws you to Broadway Presbyterian Church Nursery School? _______________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please provide any additional information you would like the school to have concerning your
child: ________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is applicant applying for financial aid? □ Yes □ No
If yes, please visit www.sss.nais.org and complete the online application. The school code is 157945.
Are you in any way affiliated with Broadway Presbyterian Church? _______________________
______________________________________________________________________________
Please indicate any family members or friends who have been or are in any way affiliated with
the Nursery School:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Applicant Name: ________________________
I/We hereby make application for the admission of my/our child to Broadway Presbyterian
Church Nursery School. I/We have enclosed a check in the amount of $40, a non-refundable
application fee, payable to Broadway Presbyterian Church Nursery School.
_______________________________
Signature of parent/guardian
_______________________________
Signature of parent/guardian
Date: _______________
Date: _______________
Please Note:
*We will contact you to arrange a tour (adults only) in the fall and a play visit for your
child in winter. For two-parent families, we ask that we have the opportunity to meet both
parents during the admissions process.
*To help us remember your child and family during the application process, please attach a
recent family photo.
*Enclose the $40 application fee and mail to:
Broadway Presbyterian Church Nursery School Admissions
601 West 114th Street
New York, NY 10025
FOR OFFICE USE:
Date received: ____________
App fee check no._________
Tour Date: _______________
Play Visit Date: ___________
Addt’l notes:
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