Welcome to Perry Nursery School

734.677.8130 • info@perrynursery.com

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Help for the Present...

Hope for the Future

Programs

Program Overview

Preschool Enrollment

Enrollment Form

FAQ

The program is great. The teachers are caring. My child loves it.

Perry Enrollment Form
Child's Name:	First: Last:
Middle Name:
Date of Birth:	Please enter the month and year in the boxes. Choose the day from the calendar.
Gender:	Male Female
Potty Trained:	Yes No
Street Address:
City:
State:
Zip:
Housing:	Rent Own
Since what year?
School District:
Race/Ethnicity:	Hispanic American Indian/Alaskan Native Arab/Middle Eastern Asian/Asian American Black/African American Native Hawaiian/Pacific Islander White/Caucasian
FAMILY INFORMATION
Parent #1
Name:	First: Last:
Phone Cell:
Phone Home:
Phone Work:
E-Mail Address:
Parent #2
Name:	First: Last:
Phone Cell:
Phone Home:
Phone Work:
E-Mail Address:
Custodial Parent(s) Marital Status:	Single Married Remarried Divorced Separated Living Together Widowed
	Has Sibling(s)
Sibling #1 Name:	First: Last:
Date of Birth:	Please enter the month and year in the boxes. Choose the day from the calendar.
	Has Another Sibling
Sibling #2 Name:	First: Last:
Date of Birth:	Please enter the month and year in the boxes. Choose the day from the calendar.
	Has Another Sibling
Sibling #3 Name:	First: Last:
Date of Birth:	Please enter the month and year in the boxes. Choose the day from the calendar.
	Has Another Sibling
Sibling #4 Name:	First: Last:
Date of Birth:	Please enter the month and year in the boxes. Choose the day from the calendar.
DIAGNOSED DISABILITY OR IDENTIFIED DEVELOPMENTAL DELAY	Low birth weight-under 5 lbs 8oz Diagnosed child immaturity Receives WIC IEP (Individualized Education Plan) Child has diagnosed disability Early On Services Child has long term or chronic illness Referral by Doctor, ISD, or parent for screening High Lead Level Therapy (Speech, OT, PT) Speech difficulties, difficult to understand, difficulty expressing needs, does not speak in whole sentences None of the Above
Comments:
Birth Weight Pounds:
Ounces:
CHILD BEHAVIORS	Child is destructive or violent Child in counseling or therapy or referred Child has been asked to leave a Preschool or Child Care None of the Above
Comments:
PARENT EDUCATIONAL ATTAINMENT	Low parent(s) or older sibling educational attainment Parent(s) or older siblings have dropped out of school Parent(s) or older siblings cannot read. Not Applicable
Comments:
Primary language spoken in the home:
Languages spoken by the child:
ABUSE, NEGLECT IN HOME	Someone in our home was a victim of physical, sexual or emotional abuse or neglect. There is a history of substance abuse in our family (alcohol, drugs, prescription drugs, etc). Someone in our home has violent, destructive temperament. Not Applicable
Comments:
ENVIRONMENTAL FACTORS	I am a single parent My child is/has been in Foster care Someone in our home is/was in jail or prison Frequent moves Unemployed parent(s) Our home is or was in foreclosure Teen parent - Under 20 years old at birth of first child Homeless Child has experienced the loss of a parent or sibling by death or loss of parent by divorce, military service, out of town employment, etc. Child has a chronically ill parent or sibling (behavior issues, physical, mental or emotional illness) Living in a high crime area/unsafe housing environment None of the Above
Comments:
How many times have you moved in the last 2 years?
We are living with:	Family (Grandparents, etc.) Friends Shelter Other
Describe:
My child's general health:	Excellent Good Fair Frequently ill
Explain/Comments:
List any medication your child is currently taking:
List any allergies (food, bee stings, medicine):
Any other limitations or conditions we should be aware of:
INCOME AND TUITION RATE DETERMINATION
Number of Adults in household:
Number of Children in household:
Source 1 Monthly Amount Received
Unemployment:
Child Support:
Alimony:
Pensions:
Retirement SSI:
Disability SSI:
TANF eligible:	Daycare payments or cash assistance
Subsidized meal form:	Requires staff verification
Verbal Disclosure:
Wages:
Other:

	Two or more adults in household
Source 2 Monthly Amount Received
Unemployment:
Child Support:
Alimony:
Pensions:
Retirement SSI:
Disability SSI:
TANF eligible:	Daycare payments or cash assistance
Subsidized meal form:	Requires staff verification
Verbal Disclosure:
Wages:
Other
Family Income:
	Monthly before taxes Annual after taxes