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. 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/Threes Virtual (TTh 9:00AM) + Outdoor Modified Cooperative (M or Th 1:30PM) - Kinn
Beginners/Threes Virtual Only Modified Cooperative (TTh 9:00AM) + Virtual 1-on-1 w/Teacher - Kinn
Fours Virtual (TWF 10:30AM) + Outdoor Modified Cooperative Th 1:30PM - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual (TWF 1:30PM) + Outdoor Modified Cooperative (Th 1:30PM) - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual Only Modified Cooperative (TWF 10:30AM) - Chapman
Fours Virtual Only Modified Cooperative (TWF 1:30PM) - Chapman
Pre-K Virtual + Outdoor Modified Cooperative (MTWTh 1:30PM) - Hall (Virtual)/Kinn (In-Person)
Pre-K Virtual Only Modified Cooperative (TWTh 1:30PM) - Hall
I wish to enroll in add-on class(es) only

2nd Choice Primary Class*

Beginners/Threes Virtual (TTh 9:00AM) + Outdoor Modified Cooperative (M or Th 1:30PM) - Kinn
Beginners/Threes Virtual Only Modified Cooperative (TTh 9:00AM) + Virtual 1-on-1 w/Teacher - Kinn
Fours Virtual (TWF 10:30AM) + Outdoor Modified Cooperative Th 1:30PM - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual (TWF 1:30PM) + Outdoor Modified Cooperative (Th 1:30PM) - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual Only Modified Cooperative (TWF 10:30AM) - Chapman
Fours Virtual Only Modified Cooperative (TWF 1:30PM) - Chapman
Pre-K Virtual + Outdoor Modified Cooperative (MTWTh 1:30PM) - Hall (Virtual)/Kinn (In-Person)
Pre-K Virtual Only Modified Cooperative (TWTh 1:30PM) - Hall
I wish to enroll in add-on class(es) only

3rd Choice Primary Class*

Beginners/Threes Virtual (TTh 9:00AM) + Outdoor Modified Cooperative (M or Th 1:30PM) - Kinn
Beginners/Threes Virtual Only Modified Cooperative (TTh 9:00AM) + Virtual 1-on-1 w/Teacher - Kinn
Fours Virtual (TWF 10:30AM) + Outdoor Modified Cooperative Th 1:30PM - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual (TWF 1:30PM) + Outdoor Modified Cooperative (Th 1:30PM) - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual Only Modified Cooperative (TWF 10:30AM) - Chapman
Fours Virtual Only Modified Cooperative (TWF 1:30PM) - Chapman
Pre-K Virtual + Outdoor Modified Cooperative (MTWTh 1:30PM) - Hall (Virtual)/Kinn (In-Person)
Pre-K Virtual Only Modified Cooperative (TWTh 1:30PM) - Hall
I wish to enroll in add-on class(es) only

4th Choice Primary Class*

Beginners/Threes Virtual (TTh 9:00AM) + Outdoor Modified Cooperative (M or Th 1:30PM) - Kinn
Beginners/Threes Virtual Only Modified Cooperative (TTh 9:00AM) + Virtual 1-on-1 w/Teacher - Kinn
Fours Virtual (TWF 10:30AM) + Outdoor Modified Cooperative Th 1:30PM - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual (TWF 1:30PM) + Outdoor Modified Cooperative (Th 1:30PM) - Chapman (Virtual)/Kinn (In-Person)
Fours Virtual Only Modified Cooperative (TWF 10:30AM) - Chapman
Fours Virtual Only Modified Cooperative (TWF 1:30PM) - Chapman
Pre-K Virtual + Outdoor Modified Cooperative (MTWTh 1:30PM) - Hall (Virtual)/Kinn (In-Person)
Pre-K Virtual Only Modified Cooperative (TWTh 1:30PM) - Hall
I wish to enroll in add-on class(es) only

Enrichment Add-On Classes

You may choose multiple classes.

S.T.E.M. Explorers (In-person Outdoor) (Pre-K only) (Non-cooperative) – Friday 1:30-3:30PM – Kilburne
Book Club (Virtual) (All ages) (Non-cooperative) - Monday 9:00 – 10:00AM – Priester
Creative Kids (Virtual) (All ages) (Non-cooperative) - Monday 11:00AM – 12:00PM – Holden
S.T.E.A.M. Discoverers (Virtual)(All ages) (Non-cooperative) – Friday 9:00 - 10:00AM – Kinn
Play & Learn Club (All ages) (Non-cooperative) – Monday 10:00 – 10:40AM - Durst

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; 2020/2021 Registration, Admissions, Waiting List, and Withdrawal Policies and Procedures; and 2020/2021 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

Email

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