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Lil’ Rider Preschool |
Application
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Southwest Preschool Application Date: _________ Assurance of Confidentiality: The information on this form is being requested on a voluntary basis. The information you provide will help us to deliver or direct services most appropriate for your family’s needs. Some of the information may be used to help plan national program initiatives. If you prefer not to provide some of the information, it will not affect the services we try to deliver. However, some information is required for eligibility determination. All information will be held in strict confidence.
Section 1: Applicant Name: (child) Last: ______________________ First: ___________________ Middle: ______________ Gender: ___Male ___ Female Date of Birth: _______________ SS# _____________ Age: ________ Race/Ethnicity: __W __B __NA __H __A __PI __Other____________ Was he/she born prematurely? ____yes ___no How many months? ______________ Does your child currently have an IFSP or IEP? _____________________________ Section 2: Primary supporting adult(s) names(s) Last: ____________________ First: _____________________ __ biological parent __ adoptive parent __step parent __foster parent __grandparent __ legal guardian __ other _____________ Last: ____________________ First: _____________________ __ biological parent __ adoptive parent __step parent __foster parent __grandparent __ legal guardian __ other _____________ Living Address _________________________ City _______________ State/zip________ Mailing Address _______________________ City ________________ State/Zip_______ Home phone ________________ Work phone ____________ Cell phone ___________ Is this person employed or in school? (specify) __Employed __Full-time __part-time __unemployed __ In school __Full-time __part-time Highest level of education completed: __G9 or less __G10 __G11 __G12 __HSG __GED __Ass.Deg __Bach Deg __Mas. Deg __College training Cert. __Some college What is the primary language spoken at home?(specify) Primary: _________________ Secondary: ________________ Is the child applying part of a dual custody family? __No __Yes (child lives in the physical custody of more than one Southwest Preschool Application Date: _________ Assurance of Confidentiality: The information on this form is being requested on a voluntary basis. The information you provide will help us to deliver or direct services most appropriate for your family’s needs. Some of the information may be used to help plan national program initiatives. If you prefer not to provide some of the information, it will not affect the services we try to deliver. However, some information is required for eligibility determination. All information will be held in strict confidence.
Section 1: Applicant Name: (child) Last: ______________________ First: ___________________ Middle: ______________ Gender: ___Male ___ Female Date of Birth: _______________ SS# _____________ Age: ________ Race/Ethnicity: __W __B __NA __H __A __PI __Other____________ Was he/she born prematurely? ____yes ___no How many months? ______________ Does your child currently have an IFSP or IEP? _____________________________ Section 2: Primary supporting adult(s) names(s) Last: ____________________ First: _____________________ __ biological parent __ adoptive parent __step parent __foster parent __grandparent __ legal guardian __ other _____________ Last: ____________________ First: _____________________ __ biological parent __ adoptive parent __step parent __foster parent __grandparent __ legal guardian __ other _____________ Living Address _________________________ City _______________ State/zip________ Mailing Address _______________________ City ________________ State/Zip_______ Home phone ________________ Work phone ____________ Cell phone ___________ Is this person employed or in school? (specify) __Employed __Full-time __part-time __unemployed __ In school __Full-time __part-time Highest level of education completed: __G9 or less __G10 __G11 __G12 __HSG __GED __Ass.Deg __Bach Deg __Mas. Deg __College training Cert. __Some college What is the primary language spoken at home?(specify) Primary: _________________ Secondary: ________________ Is the child applying part of a dual custody family? __No __Yes (child lives in the physical custody of more than one parent/guardian during the enrollment year) Section 3: Application information-Family Composition Family type: __One Parent __Two Parent __Foster __Non-Parent Number of adults in Family: ___ Number of Children: ___ Total number in family: ___ Section 4: Additional Children in the Family: Name: ________________________ Date of Birth: __________________ Age:_______ Name: ________________________ Date of Birth: __________________ Age:_______ Name: ________________________ Date of Birth: __________________ Age:_______ Name: ________________________ Date of Birth: __________________ Age:_______ Name: ________________________ Date of Birth: __________________ Age:_______ Section 5: Please fill out the attached application for free and reduced lunch. Students who qualify are given priority over students who do not. If you don’t fill out the form it will be assumed your family does not qualify. Parent/Guardian Signature: ______________________________________________ Tell Me About Your Child Name ___________________________ Age _____ Date of Birth _______________ I love ________________________________________________________________________ I don’t like ____________________________________________________________________ Please tell me about your child’s favorite activities, books games etc. 1. _______________________________________________________________________ 2. _______________________________________________________________________ 3. _______________________________________________________________________ 4. _______________________________________________________________________ How does your child get along with other children?_________________________________ _____________________________________________________________________________ Does your child have any nervous habits? ________________________________________ Does your child have any allergies? ______________________________________________ Do you have any concerns about your child’s development? _________________________ _____________________________________________________________________________ Is your child on an IEP (Individual Education Plan)? ______________________________________ Is there anything else you would like me to know about your child? ____________________________________________________________________________ ____________________________________________________________________________ |