___________ County Public Schools Preschool Application

Today's Date: _______________________

Information Pertaining to Child Applying to Program

Legal name

Child's Social Security # Child's Nickname

Sex: □Male □Female Birth date (Month/Day/Year)

Race: □Black□White□Hispanic □Asian□American Indian □Other __________________________________

Family Information

Father's Full Name

Mother's Full Name

Home Telephone Number

Mailing Address (street, city, state and zip code)

Bus Information

Will your child ride the bus to school

□ Yes□ No

If yes, please give information needed to locate home where the child will get on and off the bus:

Name of Road:

Description of House:

Location of House on Road:

Name of Nearest Neighbor: Phone Number:

If home where the child will get on and off the bus is different from their residence:

Whose home is it? Phone Number:

Address

Father's Place of Employment Work Phone No. Last Grade Completed

Mother's Place of Employment Work Phone No. Last Grade Completed

Guardian's Name

Guardian's Relationship to Child (If guardian is not parent, documentation of legal guardianship must be provided.)

Income Assistance Information

Do you receive any of the following? Please check (√) □ AFDC Case # □ SSI Case # □ Food Stamps Case # □ Medical Card Case #

General Information

Person(s) with whom the child lives:

□ Mother □ Father □ Grandparent(s) □ Guardian □ Stepmother □ Stepfather □ Foster Parent □ Other _____________

Number of persons in home

Names and ages of ALL children in the home

Housing Information

Please check all that apply:

□ Single □ Married with children □ Family with preschool children □ Family with school age children □ Family with grown children □ Separated/Divorced □ Single Parent □ Living with unmarried partner □ Blended Family □ Teenage Parent □ Widow/Widower

Estimated Income Level:

□ Less than $10.000 □ $10.001 20.000 □ $20.001 35.000 □ $35.001 50.000 □ More than $50.000

Check the primary language spoken in your home: □ English □ Spanish □ Other____________

Medical Information

Doctor's Name Telephone #

Address

ǀSpecial Diet䀀lj

ǀHealth or Medical Special Needs䀀lj

ǀDoes child have history of seizures䀀lj____ Yes _____ No If Yes, please explain

ǀWhen is the best time for the Preschool teachers to visit your homeDay(s) of the week: ________________________________________________________________Time(s) of the day: ________________________________________________________________

IN CASE OF EMERGENCY, please notify: __________________________________________ Relationship_________________________ Phone # _____________________________

PARENT AUTHORIZATION/PERMISSIONS/CERTIFICATION

1. I give permission for my child to go on field trips with his/her class. Signature of Parent(s)/Guardian Date

2. CERTIFICATION OF TRUTH: I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours. Signature of Parent(s)/Guardian Date