Child's Information

Child's name

First name:
 
Middle name:
 
Last name:
 

Child's birthday

Month:
 
Day:
 
Year:
 

Current address of the child

Street Name:
 
Apt #:
 
City:
 
State:
 
ZIP:
 

What school are you zoned for?

 

Will the child be 4 years old on or before September 30, 2017?

 

Applicant's Information

Your name

First name:
 
Middle name:
 
Last name:
 

Your birthday

Month:
 
Day:
 
Year:
 

Your relationship to the child

 

Your phone number

Home/Cell #:
 
Work #:
 

Your email address

 

Family

Parent/Guardian's marital status

 

Highest level of education of parents

Mother:
 
Father:
 

Is parent currently on military deployment?

 

Was mother or father a teen parent?

 

If so, what was parent's age at child's birth?

 

Is parent incarcerated?

 

Does the child live with relatives other than parents?

 

If yes, what is the relationship of the relative to the child?

 

Is the child in foster care?

 

Homelessness

Is the child's current address, listed above, considered a temporary living arrangement?

 

If yes, what is the reason for the temporary living arrangement?

 

Child's History

Does the child have an IEP (Individual Education Plan) for special education services?

 

If yes, what is the IEP for this child?

Please provide as much detail as possible.
 

Is the child being tested for special education services?

 

Is the child suspected or thought to have a speech/language delay?

 

Is English the child's second language?

 

If yes, what is the child's primary language?

 

Please list any health problems that should be considered for this child

If there are none that you know of, please type "None"
 

Has the child been exposed to domestic violence?

 

Has the child been exposed to substance abuse?

 
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