1. education
2. school

Centreville Day School
Centreville United Methodist Church
6400 Old Centreville Road Centreville, VA 20121
571-522-1875 [email protected] www.facebook.com/CDSPreschool
Centreville Day School Application for Admission
2015-2016 School Year
The following information must be complete in order for your child to be considered for enrollment.
Please print clearly.
Child's Name: ________________________________________________________________________________
last
first
middle
Date of Birth_______/_______/________
Sex: _____________
Address: _______________________________________________________Zip Code: ____________________
Home Phone: (_____) _____________________Email address(print clearly): _____________________________
Mother/Guardian: ___________________________ Work/cell phone: (____) _____________________________
Father/Guardian: ____________________________Work/cell phone: (____) _____________________________
Primary language spoken in the home: ______________________Other languages spoken:___________________
Who cares for your child during the day? __________________________________________________________
Does your child have any allergies or health conditions?
yes______
no______
If yes, please explain___________________________________________________________________________
____________________________________________________________________________________________
How did you hear about Centreville Day School? ____________________________________________________
Information required by Division of Licensing for the State of Virginia:
Where was your child during the 2014-2015 school year?
At home _____
Daycare Center _____
Pre-School _____
Name of Center or Pre-school: ___________________________________________________________________
Address: ____________________________________________________________________________________
I commit to partnership with Centreville Day School by reinforcing English usage in the classroom through practice at
home in order to help my child better understand all aspects of school.
All information I have provided above is accurate. I understand that Centreville Day School reserves the right to
remove my child from the roster if any of the information provided on this application is found to be untrue.
___________________________________________________________________________________________
Parent/Guardian
Date
This is a two sided document- please make sure you complete the other side.
(Over)
Centreville Day School
Application for Admission 2015-2016 (cont.)
A non-refundable registration fee of $100 ($75 for CUMC members) must be included with this registration form. A
second check for one month’s tuition must also be included unless your child is a current student (tuition will be
deferred until June 1). Checks are to be made payable to CDS. Children who are not offered a class will
automatically be put on the waiting list for all choices and the tuition check will be returned. The one-time nonrefundable Supply Fee is due with the first month’s tuition payment in September or when your child is enrolled after
September.
Check one:
_____Member of Centreville United Methodist Church
_____Currently enrolled student
_____Sibling of currently enrolled student
_____Alumni family: My child ____________________________attended CDS during these years____________
_____General Public
AM session is 9:00 AM-11:45 AM
PM session is 12:30 PM- 3:15 PM
Please indicate 1st, 2nd, or 3rd (if available) choice:
Mother's Morning Out: must be 2 yrs. old by 3/31/15
Tuesday and Thursday AM: _________
Wednesday and Friday AM: _________
Non CUMC
Member
$190/month
$190/month
CUMC
Member
$185/month
$185/month
One-Time
Supply
Fee
$25
$25
3 year old program: must be 3 yrs. old by 9/30/15 and potty trained.
Tues/ Thurs AM: ____________
Tues/ Thurs PM: ____________
Mon/ Wed/ Fri AM: __________
$190/month
$190/month
$245/month
$185/month
$185/month
$240/month
$25
$25
$35
4 year old program: must be 4 yrs. old by 9/30/15 and potty trained.
Mon/ Wed/ Fri AM: __________
Mon/Tues/Thurs/Fri PM: _________
Monday- Friday AM: _________
$245/month
$295/month
$340/month
$240/month
$290/month
$335/month
$35
$45
$55
Pre K: must be 5 yrs. old by 10/30/15 or with Director’s discretion and potty trained.
Monday- Friday AM only: __________
$350/month
$345/month
$65
____________________________________________________________________________________________
Office Use only:
Registration Amt. _________________
One Month Tuition Payment Amt.________________
Check #: ________________________
Check #: ____________________________
Date Received: ___________________
Date Received: _______________________
Supply Fee Amt. _________________
Date Received: _______________________
Class Placement:
MMO_______3’s___________4’s____________Pre K______________
AM____________PM_________Days per week________________________