A Village Learning Center

Application for Admission

Application for Admission
Student's Legal Name*
First Last
Grade to be enrolled*
Date of Birth*
Date Format: MM slash DD slash YYYY
Has this student been previously applied to or attended this school?*
- Yes
- No
Student's Full Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
SCHOOL YEAR*
- 2025-26
Grade/Level:*
Is your child fully potty trained and able to use the restroom independently?*
- Yes
- No
Thank you for your interest in our program! At this time, all children must be fully potty trained—including using the restroom independently and managing personal hygiene—in order to be eligible for enrollment. If your child is not yet potty trained, we kindly ask that you wait to apply until they have reached that milestone. We’d be happy to stay in touch and revisit enrollment when the time is right. Please let us know if you have any questions—we’re here to help!
Parent/Guardian #1
Parent/Guardian’s 1 Name*
First Last
Phone*
Email Address*
Business/Cell Phone*
Occupation*
Place of Business*
Business Address*
Parent/Guardian #2
Parent/Guardian’s 2 Name
First Last
Phone
Email Address
Business/Cell Phone
Occupation
Place of Business
Business Address
People allowed to pick up student
List people allowed to pick up student*
Name Phone Relationship

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In the event of an emergency, if the parents cannot be reached, please contact:
Emergency Contact*
Name Address Phone Relationship

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Do both parents now live with the child?*
- Yes
- No
If not, which parent has custody?*
Medical Information:
Primary Doctor's Name*
Phone Number*
Address*
Insurance Provider*
Preferred Hospital*
Please list any health or medical concerns including current medications and/or allergies*
Previous School Name*
Name State Dates Enrolled (from) Dates Enrolled (to)

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Did you child attend preschool?*
- Nes
- No
Name of preschool*
State*
Years attended (____ to ___)*
Does your child have an IEP or 504 plan?*
- Nes
- No
Is there any other information that I need to know to help better connect and guide your child?*
What are your learner's strengths and interests?*
What are the common situations in which your learner expresses frustration?*
What are two goals you would like to achieve this school year?*
Signature*
Date
Date Format: MM slash DD slash YYYY

Please note that all information provided on this form will be kept confidential.

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Name	Phone	Relationship

Name	Address	Phone	Relationship

Name	State	Dates Enrolled (from)	Dates Enrolled (to)

A Village Learning Center

Application for Admission

Parent/Guardian #1

Parent/Guardian #2

People allowed to pick up student

In the event of an emergency, if the parents cannot be reached, please contact:

Medical Information:

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