Student Information

To be placed on the waiting list for: Age: ---3 year old4 year old School Year: ---2011-20122012-2013
Student's name: First: Middle: Last:
Student's date of birth: Student's current age:
Student's gender: ---MaleFemale
Preschool:
Special Education: has student been:  recommended for tested for qualified for services?
At what school? What type?
What is the primary language spoken by the student?
School previously attended:
Does the child have siblings currently attending Valley Academy?  No Yes
If yes, please provide name(s) and grade(s) of siblings:

Contact Information

Home phone number: Alternate phone:
Email Address:
Street Address: City, State, Zip:

Parent Information

Mother's Name:
Mother's work number:
Father's Name:
Father's work number:
Legal Custody:  Both Parents Mother Father Other
Other - please explain:

Other Information

Choose an AM or PM preference
 AM class 8:30a.m.-11:00a.m. PM class 12:00p.m.-2:30p.m.

How did you hear about Valley Academy?
 Friend Website Advertisement Flyer Phone Book Other
Other - please explain: