(310) 748­-1656
(323) 876­-0644

Application For Admission

Today’s Date _________________________               Desired Starting Date ______________________

CHILD INFORMATION

First Name: ______________________________   Last Name:_______________________________

Street: ____________________________________________________________________________

City: State: ZIP: _____________________________________________________________________

Birth date: _____________________________________________Check one: ___ Male ___ Female

Lives with:     _____Both parents ____ Mother   _____ Father _____ Other __________________________

Any allergies that child has: _____________________________________________________________

PARENT/GUARDIAN INFORMATION

Child’s Mother_______________________________________ Occupation_______________________

(or Guardian 1)

Home Tel:____________________________ Cell Tel:_____________ Work Tel:____________________

Home Address (if different from Child’s): ______________________________________________________

Employer: ____________________________________________________________________________

E-mail ______________________________________________________________________________

Child’s Father_______________________________________ Occupation________________________

(or Guardian 2)

Home Tel:_____________________________ Cell Tel:_____________ Work Tel:____________________

Home Address (if different from Child’s): ______________________________________________________

Employer: ____________________________________________________________________________

E-mail _______________________________________________________________________________

Parent(s)/Guardian(s) are: ___ Married ___ Single ___ Separated ___ Divorced ___ Widowed

___ Grandparent(s) ___ Legal Guardians ___ Other (please explain): ________________________

 

Please share with us your goals for your child.

__________________________________________________________________

__________________________________________________________________

How do you see your child’s learning style, social and emotional interactions?

__________________________________________________________________

__________________________________________________________________

What do you expect the school to do for your child?

__________________________________________________________________

__________________________________________________________________

Please share with us any medical history that would help us to better understand your child.

__________________________________________________________________

How did you learn about West Hollywood Children’s Academy?

__________________________________________________________________

Additional comments or observations you feel we should know to help us understand your

child better: ___________________________________________________________________________

______________________________________________________________________________________

Name of Parent/Guardian completing this form   ____________________________________________

Signature of Parent/Guardian completing this form ___________________________________________

Date: ___ / ___ / ___

*Please return your application with a photo of your child and $100 Non-refundable Application fee. Application fee could be used towards enrollment fee. Thank you!

"We know our children not only by reason
but also by the heart."

– B. Pascal
West Hollywood Children's Academy