Thank you for choosing to apply at Pali Preschool for your child’s educational

foundation.

To apply your child to our school simply fill out our Student Application. Those that

submit their application by October 31 will be considered for the first round of

applicants. Applications will be accepted after October 31 and until classes are filled.

The application process is a 3 step process. Following receipt of the application (step 1)

applicants are invited to attend an Assessment (step 2). The Assessment is an

opportunity to better acquaint ourselves with your child and his/her abilities. After

being accepted to Pali Preschool parents will be invited to a Parent Interview with the

Director (step 3). The purpose of the interview is to get better acquainted, discuss

parent and school expectations, and begin our working relationship.

Pali Preschool seeks future students that are ready to begin either on the first day of

school or at the time of availability. Tuition is an annual tuition and parents are given

the opportunity to either pay in full or in monthly installments. Because tuition covers

the financial needs of the school (personnel and business expenses) families looking to

enroll their child after the school start date must either pay tuition from the first day of

school or remain on the active waitlist until a future opening becomes available.

Should have any questions about Pali Preschool please feel free to contact us at (808)

523-6495. Thank you for choosing Pali Preschool!

Pali Preschool Student Application Date of Application: __________________

467 N Judd Street, Honolulu Hi 96817 (808) 523-6495 Desired Start date:_________________

A non-refundable application fee of $50.00 must be submitted with application Actual Start date:__________________

APPLICANT INFORMATION:

Student’s Name _______________________________________________________ Nickname_________________________________

Address_______________________________________________________________________________________________________ Number and Street City State Zip

Home Phone__________________________ Birth date _______________________ ( )Male ( )Female

Name of siblings who previously attended Pali Preschool:________________________________________________________________

PARENT/GUARDIAN INFORMATION:

Dr Mr. Mrs. Ms. Dr Mr. Mrs. Ms.

_____________________________________________ ______________________________________________ Name Name

_____________________________________________ ______________________________________________ Home Phone Cell Phone Home Phone Cell Phone

_____________________________________________ ______________________________________________ E-mail Address E-mail Address

_____________________________________________ ______________________________________________ Place of Employment/Occupation Place of Employment/Occupation

_____________________________________________ ______________________________________________ Employer Work Phone Employer Work Phone

Parents’ Status: Married Single Legally separated* Divorced* Deceased parent:___________________

Who has physical custody of the applicant? __________________________________________ _________________________________________

Name(s) Relationship(s)

If parents live separately, do you desire correspondence to be mailed to each parent? Both Mother only Father only

Current Preschool/Child Care Center: _________________________________________________ Dates Attended: _______________

How did you hear about Pali Preschool? _____________________________________________________________________________ Why did you choose Pali Preschool for your child? _____________________________________________________________________

______________________________________________________________________________________________________________ What do you see as your part in your child’s education? _________________________________________________________________ ______________________________________________________________________________________________________________

Has your child ever been tested by the DOE or other agencies? ____________ When? ___________________________________

What were the results? (please provide us a copy of the results) _________________________________________________________________________________

May we have permission to contact your child’s current provider/teacher? YES NO N/A

If by personal reference, Name of person(s) who referred you ________________________________ Relationship: _________________ Parent/Guardian Signature & Date ___________________________________ Parent/Guardian Signature & Date _______________________________________

FOR OFFICE USE ONLY Visitation Date ______________________________ Application Received __________________________ Form of Payment __________________ Notes: ________________________________________________________________________________________________________________

Revised 1/2018

Emergency & Consent Forms (To be kept with child’s file in the Preschool Office)

Child’s name ________________________________________________________________

AUTHORIZATION TO RELEASE: List anyone who can be called to pick up your child, including parents on a daily basis and in case of illness. For your child’s protection we will not release your child to anyone other than the persons listed below. It is the policy of Pali Preschool to contact the parents of a child regarding medical treatment if the child is seriously injured or becomes ill at school. When necessary, children will be taken by ambulance to the nearest emergency medical facility. Any changes must be with written notice to the PPS office & amended on this form. Please list at least 2 other person besides the parent(s). Persons must be 16 years old or older.

Name Relationship Phone#

__________________________ ______________________ ____________

__________________________ ______________________ ____________

__________________________ ______________________ ____________

__________________________ ______________________ ____________

__________________________ ______________________ ____________

MEDICAL INFORMATION:

Family Physician ______________________________________ Phone _______________

Family Dentist ________________________________________ Phone _______________

My child receives regular care for the following medical conditions:

( ) No medical condition

( ) Yes. Please check below:

( ) Allergy ( ) Bee Sting ( ) Food ( ) Medications ( ) Other: LIST_______________

If allergy, please list allergy and reaction:

_____________________________________________________________________

_____________________________________________________________________

Note: Lunch & snacks are provided at our facility. Menus are posted monthly. Substitutions can be made for children with food allergies by providing the center with verification from child’s doctor stating the allergy. For children who are lactose tolerant, the parent needs to bring their milk substitute (i.e. soy milk).

If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for school authorities to take appropriate action for the safety and welfare of my child. _________________________________________________ ______________________________________________ Parent/Guardian’s signature Date Parent/Guardian’s signature Date

My child has health insurance: ( ) Yes ( ) No If YES, check: ( ) Private OR ( ) QUEST/Medicaid If private, check your plan: ( ) HMSA ( ) Kaiser ( ) Tri-Care ( ) Other: __________

Pali Preschool Child’s (Developmental) History

The information shared will assist the teachers in understanding and helping your child. All information will be kept strictly confidential.

Child’s Name_________________________________ Date of Birth ________________ “Nickname” __________________________________ HOMELIFE

Parent / Guardian First & Last Name _____________________ ____________________ Parent / Guardian First & Last Name _____________________ ____________________ Are the child’s parents living together? __________________ Occupation of Mother _______________________ Occupation of Father _______________________ Any siblings? If yes, please list name & ages _______________________________________________________________________________________________ Are there other relatives or persons living with the family other than those listed above? ________________________________ _______________________________________________________________ ________________________________ _______________________________________________________________

Has the family made any moves or any major changes in the last three years? __________________________________________________________________________________________________

_______________________________________________________________________________________________

Are other languages spoken in the home and to what extent? ____________________________________________

SCHOOL LIFE

Has your child ever attended daycare, another preschool facility or been in a preschool setting? If so, please indicate which program your child previously attended and the reason for the change. __________________________________________________________________________________________________

_______________________________________________________________________________________________

Describe your child’s attitude towards learning? _______________________________________________________________________________________________ We are a Christian Preschool. Do you have any objections to your child being exposed to spiritual development? ________________________________________________________________________________________________ What are your plans for your child for Kindergarten? ___________________________________________________

PROFILE OF THE CHILD

What are your child’s greatest strengths? ______________________________________________________________ What are your child’s weaknesses? ___________________________________________________________________ Describe your child’s general personality _______________________________________________________________ Does your child usually nap? Please list problems or special needs connected with sleep. _______________________________________________________________________________________________ Does your child have any certain habits ________________________________________________________________ List any definite FEARS/STRESS ____________________________________________________________________ In those times, what comforts your child _______________________________________________________________ Any particular INTERESTS? _______________________________________________________________________ Bedtime: ______________ Wake up time: ______________ Appetite: __________________ Is your child potty trained DURING THE DAY? YES NO Is your child potty trained DURING THE NIGHT? YES NO Any regression in potty training? What triggered it? What are your child’s bathroom schedule/needs? _______________________________________________________________________________________________ _______________________________________________________________________________________________ Is your child respectful of you? Describe the form of discipline that is used at home? How does your child respond?

________________________________________________________________________________________________

________________________________________________________________________________________________

What goals do you have for your child while in preschool? _________________________________________________

________________________________________________________________________________________________

Why would Pali Preschool be a good environment for your child? ____________________________________________

________________________________________________________________________________________________

Is your child on a waiting list at another preschool? _______________________________________________________ Anything about your child, his/her personality, temperament, any “unique” behaviors, etc. that you would like to share with the faculty that would be helpful in helping to better know, understand and work with your child. Please feel free to attach a separate sheet of paper if necessary. Thank you! __________________________________________________________________________________________________

__________________________________________________________________________________________________

______________________________________________________________________________________________

Revised 1/2018

Pali Preschool

Confidential Report

Child’s Name: __________________________________________ DOB: ________________

Parent/Guardian: Please have your child’s current teacher/child care provider complete this report. Information on this report is confidential and will not be shared beyond the admission committee. I agree to have this form completed by my child’s former provider. In addition, I give Pali Preschool permission to contact my child’s former Teacher/child care provider to discuss any questions Administration may have.

Parent/Guardian Signature: _______________________________ Date: ________________ Type of preschool program provided: (i.e. Montessori, Traditional, day care, family childcare, etc.) Please Circle the Appropriate Rating(s):

Self Motivation does very little only that required set high goals Some desire to learn well motivated Intellectual Curiosity limited an occasional spark one area only Strong and varied intense and varied Ability to work in a group has great difficulty sometimes unable to cope Usually effective always works well Ability to work alone needs much supervision needs help frequently Needs help occasionally always works well Ability to express ideas limited has some difficulty Orally good exceptionally good Use of time uses poorly occasionally wastes Usually uses well always uses effectively Follows directions needs explanation occasionally needs help Quickly and correctly Seeks help when rarely occasionally Needed usually always Attention span easily distracted occasionally distracted Usually good exceptionally good Maturity in terms of age very mature somewhat immature normal And development above average very mature Consideration of others thoughtless seldom considerate Usually considerate always considerate Social adjustment has serious problems has frequent minor problems

With peers Very healthy has occasional minor problems Leadership potential a follower leads when put in position A natural leader seeks opportunities and uses them well Initiative never initiates rarely shown Occasionally initiates frequent display Classroom conduct negative instigator occasionally disrupts Usually good always good Emotional Stability insecure overly tense Attention giver stable Personality withdrawn/shy overly aggressive delightful Pleasing unusually interesting Self Confidence needs much reassurance appears overly confident Needs some support healthy self-image Takes responsibility rarely sometimes usually always For actions Cooperates with rarely sometimes usually always Adults Cooperation of parents/ poor fair good outstanding Guardians

PLEASE CIRCLE WORDS WHICH DESCRIBE THE CHILD

passive vivacious good-humored friendly well-liked aloof forthright sociable aggressive sullen shy stubborn cheerful self-centered poised nervous irritable persistent easily discouraged influential (wholesome, unwholesome)

PLEASE COMMENT ON THE CHILD’S ACADEMIC ABILITY

Able to correctly grasp a pencil Yes No Able to write own name Yes No Able to recognize letters None Few Most All Knows letter names None Few Most All Able to count by ones to _____ Able to recognize numerals ____ to ____

Comments: ____________________________________________________________________________________________________________________________________________________________ ________________________

Teacher Name (please print): _____________________________________________________________________ Teacher Signature: ______________________________________________________ Date: _________________ Name of Preschool/Child Care Center: ______________________________________________________________

Mail directly to: Pali Preschool; 467 N Judd Street; Honolulu HI 96817 Email to: info@palipreschool.com Eff 18/19