2021-2022 Application

Child's Name*

First Last

Name Called

Birthdate*

Gender*

Male
Female

Is your child currently enrolled at CPI?*

Yes
No

If yes, which class?

If no, how did you hear about us?

My child is the sibling or child of another current student or CPI alumni.
I’ve heard great things about CPI from friends and neighbors!
I found you on Facebook.
I read about you online.

Name of student/alumnus

Name of referral

Name of site

Optional: What is the student’s ethnicity/race?

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Optional: Is this student Hispanic or Latino?

No, not Hispanic or Latino
Yes

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Father's Name*

First Last

Father's Employer*

Father's Email*

Father's Work Phone*

Father's Cell Phone*

Mother's Name*

First Last

Mother's Employer*

Mother's Email*

Mother's Work Phone*

Mother's Cell Phone*

May we publish your cell phone number(s) on our Parent Class Roster (only distributed to other families in your child’s class)?*

Yes
No

List any other email addresses for school newsletters, etc.

Please provide names and date of birth for any younger children for CPI’s alumni list:

References

For state licensing purposes, we are required to obtain personal references for each CPI parent member. Please provide information for two friends or associates (must not be related to you) for use as personal references. If you can use a current CPI member as your reference, only one name is required.

Reference 1 Name*

First Last

Reference 1 Address*

Street Address Address Line 2 City State ZIP Code

Reference 1 Phone*

Is this person a CPI member?*

Yes
No

Reference 2 Name

First Last

Reference 2 Address

Street Address Address Line 2 City State ZIP Code

Phone

Is this person a CPI member?

Yes
No

Class Selections

Click here to view our class offerings & tuition costs. As class space is limited, please rank as many options as possible. Read the Parent Participation Requirements for information on each class type. All classes are subject to change at any time at the discretion of the Board of Directors.

1st Choice Primary Class*

Beginners 2-Day AM (School Cooperative) (M/W 8:55-11:40AM)
Threes 3-Day AM (Cooperative) (M/W/F 8:50-11:35AM)
Fours 3-Day AM (Cooperative) (M/W/F 8:45-11:30AM)
Fours 3-Day PM (Cooperative) (M/W/F 12:35-3:20PM)
Pre-K 4-Day PM (Semi-Cooperative) (MTWTh 12:30-3:15PM)
I wish to enroll in add-on class(es) only

2nd Choice Primary Class*

Beginners 2-Day AM (School Cooperative) (M/W 8:55-11:40AM)
Threes 3-Day AM (Cooperative) (M/W/F 8:50-11:35AM)
Fours 3-Day AM (Cooperative) (M/W/F 8:45-11:30AM)
Fours 3-Day PM (Cooperative) (M/W/F 12:35-3:20PM)
Pre-K 4-Day PM (Semi-Cooperative) (MTWTh 12:30-3:15PM)
I wish to enroll in add-on class(es) only

3rd Choice Primary Class

Beginners 2-Day AM (School Cooperative) (M/W 8:55-11:40AM)
Threes 3-Day AM (Cooperative) (M/W/F 8:50-11:35AM)
Fours 3-Day AM (Cooperative) (M/W/F 8:45-11:30AM)
Fours 3-Day PM (Cooperative) (M/W/F 12:35-3:20PM)
Pre-K 4-Day PM (Semi-Cooperative) (MTWTh 12:30-3:15PM)
I wish to enroll in add-on class(es) only

4th Choice Primary Class

Beginners 2-Day AM (School Cooperative) (M/W 8:55-11:40AM)
Threes 3-Day AM (Cooperative) (M/W/F 8:50-11:35AM)
Fours 3-Day AM (Cooperative) (M/W/F 8:45-11:30AM)
Fours 3-Day PM (Cooperative) (M/W/F 12:35-3:20PM)
Pre-K 4-Day PM (Semi-Cooperative) (MTWTh 12:30-3:15PM)
I wish to enroll in add-on class(es) only

Add Buy Out option for Primary Class

3-Day Threes/Fours Co-op Class Buy Out (Additional fee)
4-Day Pre-K Co-op Class Buy Out (Additional fee)

Enrichment Add-On Classes

You may choose multiple classes.

S.T.E.M. Explorers (Non-cooperative) (Pre-K & Fours AM only) – Friday 12:30-3:15PM
Book Club (Pre-K & Fours AM only) (Non-cooperative) - Tuesday 8:45-11:30AM
Creative Kids (Beginners & Threes 3-Day AM only) (Non-cooperative) - Thursday 8:55-11:40AM
Lunch Bunch (for Pre-K transitioning from Book Club to Pre-K only) (Non-cooperative) – Tuesday 11:30AM-12:30PM
Lunch Bunch (for Fours transitioning from Fours to STEM only) (Non-cooperative) – Friday 11:30AM-12:30PM

CPI may offer a Virtual Preschool class and/or Virtual Enrichment classes. Are you interested in enrolling in a virtual class?*

Yes
No

Comments about Virtual Class options

Consent*

Please click here to download this document for future reference.

I have been provided with copies of the following: CPI’s Parent Participation Requirements; 2021/2022 Registration, Admissions, Waiting List, and Withdrawal Policies and Procedures; and 2021/2022 Membership Agreement; and I agree to abide by the policies and procedures therein.

Signature*

Payment Method*

*Only 1 registration fee is required per family each school year. A $2 processing fee will be added for credit card payments.

Credit Card
Check
I've already paid the registration fee for this child's sibling.

Registration Fee

$0.00

Please write a check for $65 and payable to CPI. Be sure to write your child's name in the Memo field.

Mail your check to:
Enrollment Director
Centreville Preschool, Inc.
PO Box 253
Centreville VA 20122

Your child's application will be processed once your check is received.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Phone

This field is for validation purposes and should be left unchanged.

References

Class Selections

Please write a check for $65 and payable to CPI. Be sure to write your child's name in the Memo field.

Mail your check to: Enrollment Director Centreville Preschool, Inc. PO Box 253 Centreville VA 20122

Your child's application will be processed once your check is received.

Mail your check to:
Enrollment Director
Centreville Preschool, Inc.
PO Box 253
Centreville VA 20122