Child's Name* First Last Name Called Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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: ReferencesFor 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneIs this person a CPI member? Yes No Class SelectionsClick 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 ClassesYou 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 ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.
