Bluejay Beginnings Preschool
4-Year-Old
Preschool
Anderson Elementary
Lottery Application & Information
REQUIREMENTS:
*Child must be 4 on or before September 15, 2017.
*Children who are 5 on or before September 15 are not eligible.
*Child must live within the Bondurant-Farrar School District
Child’s Legal Name: First
Last
Date of Birth
Parent/Guardian Name 1
Parent/Guardian Name 2
Email
Phone
Street Address and/or P.O. Box
City
Male______
Female ______
Zip Code
Family InformationRelationship to child
Parent/Guardian 1
Ethnicity
Work Status
Child’s type
of insurance
No
Yes
Where:
No
Yes
Where:
Parent/Guardian 2
Children in the household
Name
______________________________
______________________________
______________________________
______________________________
______________________________
Age
_____
_____
_____
_____
_____
School/Daycare Name
________________________________
________________________________
________________________________
________________________________
________________________________
Health and/or developmental concerns for applying child?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Signature of person completing application _____________________________________
Date _____________
My class preference is: _____4-year-old program Tues-Fri Mornings 8:30-11:30
_____4-year-old program Tues-Fri Afternoons 12:30-3:30
_____ No preference
We will do our best to accommodate your session request. Please note any special considerations such as carpooling with
another child or daycare arrangements.
_______________________________________________________________________________________________________
Revised 11/2015