APPLICATION St. Charles School District Early Childhood Preschool Program

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1 APPLICATION St. Charles School District Early Childhood Preschool Program Serving preschool children who are at least three years of age before August 1, 2014 Offering preschool classes at all elementary schools (dependent upon enrollment). Half day and full day options are available at certain schools. Blackhurst Elementary Harris Elementary Monroe Elementary 2000 Elm Street Road 2800 Old Muegge Road 2670 Zumbehl Road Coverdell Elementary Lincoln Elementary Null Elementary 2475 West Randolph Street 625 South Sixth Street 435 Yale Boulevard PRESCHOOL APPLICATIONS ARE DUE BY March 4, 2014 for first round consideration of Title I funds. Applications received after this date will be considered on a first-come, first-served basis. Accreditation The St. Charles R-VI School District Preschool Program has been accredited by the Missouri Accreditation of Programs for Children and Youth. Following is an excerpt of the March 16 th, 2012 press release: The St. Charles R-VI School District Preschool Program achieved recognition of excellence through Missouri Accreditation. This distinguishes it as an exemplary program offering high quality programming to the children of Missouri. The Missouri Accreditation of Programs for Children and Youth has awarded a Certificate of Accreditation to all six sites of the St. Charles R-VI Preschool Program. This certificate is granted to quality programs that offer developmentally appropriate experiences in an environment conducive to children flourishing intellectually, emotionally, socially, and physically. The community of St. Charles, Missouri is fortunate to have a program such as The St. Charles R-VI School District Preschool Program available to serve its families. Page 1

2 What do we offer? The St. Charles School District Early Childhood Preschool Program is an integrated program that meets children s educational needs and is developmentally appropriate for all children. Experiences are provided to stimulate learning in the physical, social, emotional, cognitive, adaptive, and communication developmental areas so that all children may reach their potential through developmentally appropriate activities. Each child is viewed as a unique person with an individual pattern and timing of growth and development. Who is working with your child? The St. Charles School District Early Childhood Preschool Program employs certified teachers with degrees in Early Childhood Education and Early Childhood Special Education. We also provide well-trained teacher assistants who help prepare the environment for children and their interaction with peers and adults. What is our philosophy? The St. Charles School District Early Childhood Preschool Program operates under the philosophy that learning is child-centered, process oriented and choice driven. A variety of learning opportunities are provided, such as language and literacy, dramatic play, blocks, science, math, games, puzzles, books, art, music and motor skill development. Instruction is organized in thematic units. Children learn through play in a safe environment that fosters discovery while building on each child s strengths. Teachers facilitate the development of self-control in children by using positive guidance techniques such as modeling and encouraging appropriate behaviors, redirecting, and setting clear limits. What is our curriculum? The St. Charles School District Early Childhood Preschool Program implements a developmentally appropriate practices curriculum. The focus is hands-on learning from experiencing a variety of classroom activities. Each activity is chosen based on the developmental skills of the children. This practice promotes independence and enhances thinking skills. All classrooms are well equipped with developmentally appropriate materials. Both sites have outdoor play areas designed for young children. The early childhood preschool implements the Project Construct curriculum, and the student s developmental progress is assessed using a variety of methods. Page 2

3 Enrollment is open to children who are at least 3 years old before August 1, Title I funded preschool spaces are reserved exclusively for qualifying St. Charles School District resident children who attend the half day preschool program. While non-resident students may apply for tuition paying preschool slots, first priority for enrollment will be for resident students. All students are required to enroll for Monday through Friday classes. Parents are responsible for providing transportation to and from school. The early childhood preschool offers classes that are multi-age groupings of preschool children. Learning and instruction is individualized as children progress at their own rate and experience success. Research shows that when the classroom is composed of a community of learners with a range of abilities and ages, there are measurable gains in socialization, independence, and interaction with peers. Younger children will be nurtured by older children and benefit from collaborative learning. Older children will show increased levels of competence and leadership. Consideration will be given to the balancing of ages in each classroom. All classes will employ at least one certified teacher and additional adults according to Missouri State Accreditation child to teacher ratio. The following are required upon admittance into the program: Be willing and able to provide transportation for your child to and from school Be responsible for making sure your child attends school every day Agree to automatic withdrawal of funds from a checking or savings account for monthly tuition payments PRESCHOOL LOCATIONS AND TIMES Half day and full day options are available at certain schools. The half day preschool classes will operate on the district s preschool (170 day) calendar and the full day preschool classes will operate on the district s student (176 day) calendar. Classes will be offered at the following times: Half Day Morning Preschool Half Day Afternoon Preschool Full Day Preschool 8:30 am 11:30 am: 12:30 pm 3:30 pm: 8:30 am 3:30 pm: Blackhurst Elementary Monroe Elementary Blackhurst Elementary and/or Coverdell Elementary Null Elementary Coverdell Elementary Harris Elementary Lincoln Elementary The St. Charles School District Early Childhood Half Day Preschool Program offers five day - three hour sessions - Monday through Friday. Depending on location, extended day child care options are also available from 7:00 am until 6:00 pm, dependent upon enrollment. Full Day preschool classes are available at Blackhurst and/or Coverdell Elementary Schools, dependent upon enrollment - Monday through Friday - 8:30 am to 3:30 pm with extended day child care options available 7:00 am until 6:00 pm dependent upon enrollment. Page 3

4 PRESCHOOL TUITION REQUIREMENTS Payment via Direct Deposit is required. Tuition payments are due on the 1 st of the month. A $ non-refundable deposit is required to reserve a tuition-paying preschool spot. This fee will be applied to the May tuition bill. HALF DAY PRESCHOOL TUITION Half Day Preschool tuition is $3, per year based on a 170 day preschool calendar. Each child will receive a $ scholarship which brings the tuition rate down to $2, per year. If comparing our tuition rates with other area programs, the below comparison rates chart is provided for your convenience. HALF DAY PRESCHOOL MONTHLY PAYMENTS 9 Monthly Payments Begins August and concludes in May $ No payment is collected during the month of December! HALF DAY PRESCHOOL COMPARISON RATES Yearly $3, Scholarship $ Tuition Due $2, Monthly Payments = $ per month 36 Weeks = $77.78 per week 170 Days = $16.47 per day FULL DAY PRESCHOOL TUITION Full Day Preschool tuition is $6, per year based on the 176 day district student calendar. Each child will receive a $1, scholarship which brings the tuition rate down to $5, per year or will qualify for tuition reduction through a sliding scale for qualifying families. If comparing our tuition rates with other area programs, the below comparison rates chart is provided for your convenience. 9 Monthly Payments Begins August and concludes in May $ No payment is collected during the month of December! Page 4 FULL DAY PRESCHOOL MONTHLY PAYMENTS Yearly $6, Scholarship $1, Tuition Due $5, Monthly Payments = $ per month 36 Weeks = $ per week 176 Days = $31.82 per day FULL DAY PRESCHOOL COMPARISON RATES

5 SLIDING SCALE TUITION FULL DAY PRESCHOOL ONLY (Pending Missouri Preschool Program Grant Funding) Full Day Tuition Reduced Lunch Sliding Scale is $5, per year (20% tuition reduction*). Full Day Tuition Free Lunch Sliding Scale is $4, (30% tuition reduction*). FULL DAY PRESCHOOL - SLIDING SCALE MONTHLY PAYMENTS Reduced Lunch* Free Lunch* 9 Monthly Payments Begins August and concludes in May $ $ No payment is collected during the month of December! FULL DAY PRESCHOOL - SLIDING SCALE COMPARISON RATES Reduced Lunch 20% Reduction Free Lunch 30% Reduction Yearly $5, $4, Scholarship NA NA Tuition Due $5, $4, Monthly $ $ Weeks = $ $ Days = $30.00 per day $26.25 per day *Child must be approved for free or reduced lunch by completing a Free and Reduced Price School Meals Application. (A copy of the application is attached). TITLE I FUNDING Half Day Preschool Only Upon receipt of your application, your child will be screened to determine whether they qualify for Title I funding. There will be one session of half day preschool at each site (dependent upon enrollment) with 15 to 20 students attending per session. The guidelines for the Title I early childhood preschool program state that students receiving Title I funding for their preschool tuition will be enrolled based upon greatest academic need. Student need is based upon their performance on the DIAL-4 Assessment. These positions are offered free of charge through Title I funding. The number of Title I preschool slots are dependent upon federal funding and may vary from year to year. Once the Title I positions have been determined and filled, open tuition spaces may remain. Title I funding is not available for full day preschool. CHILD CARE ASSISTANCE Upon acceptance into the preschool program, families whose child is receiving Title I funding will be required to complete the application for the Child Care Assistance Program through the Missouri Department of Social Services at Eligibility for the Child Care Assistance Program does NOT factor into preschool placement decisions. Other families may also wish to apply to determine whether they qualify for this financial assistance program. Page 5

6 Extended-Day Child Care Options Kidz Care provides high-quality child care for preschool students to compliment the preschool day. The Kidz Care program will be offered at select locations upon meeting minimum student enrollment numbers. The following schedule is offered dependent upon enrollment: Morning Preschool Kidz Care Preschool Times Kidz Care Location Blackhurst (Half Day) 7:00 am 8:30 am 8:30 am 11:30 am 11:30 am 6:00 pm Blackhurst (Full Day) 7:00 am 8:30 am 8:30 am 3:30 pm 3:30 pm 6:00 pm Coverdell (Half Day) 7:00 am 8:30 am 8:30 am 11:30 am 11:30 am 6:00 pm Coverdell (Full Day) 7:00 am 8:30 am 8:30 am 3:30 pm 3:30 pm 6:00 pm Afternoon Preschool Kidz Care Preschool Times Kidz Care Location Monroe 7:00 am 12:30 pm 12:30 pm 3:30 pm 3:30 pm 6:00 pm PAYMENT OF FEES The Kidz Care is a youth program sponsored by Adult & Community Education and is self-supported by user fees. At the time of registration, a $50.00 per family registration fee will be collected. This deposit guarantees your child s placement and is non-refundable/non-transferrable. If you are a returning family, a $30.00 registration fee will be required. Kidz Care payments are based upon the district s preschool 170 day calendar if attending half day preschool. The full day preschool Kidz Care payments are based upon the district 176 day student calendar. Payments are prorated as such across nine (9) monthly payments. (August-May with no payment in December). All tuition payments are due and payable on the 1 st day of the month for which your child will receive services. If the 1st of the month falls on a weekend, the tuition due date will be the following Monday. In order to assure your child s spot in the program, you will be responsible for tuition starting on your child s first contracted day of the program, whether your child is in attendance or not. The first tuition payment is due by August 1 for students to begin Kidz Care on August 13, Payment is accepted by Direct Debit or Credit Card only. A debit or credit card authorization form must be on file with the Adult & Community Education Office. Payments not honored by your financial institution will result in suspension of child care services. Reinstatement can occur only after all fees are paid in full. Please note that all payments are non-refundable, and no adjustments will be made for holidays, sick days, or vacation. For those families needing financial assistance, we would highly encourage completion of an application through the Child Care Assistance Program by contacting the Department of Social Services at Page 6

7 Kidz Care Tuition Rates (Based upon 5 days per week attendance) Monthly Fees Blackhurst Early AM 1.5 hrs (before preschool) (7:00 am - 8:30 am)* Coverdell Early AM 1.5 hrs (before preschool) (7:00 am - 8:30 am)* Monroe AM 5.5 hrs (before preschool) (7:00 am - 12:30 pm) Blackhurst PM 6.5 hrs (after half day preschool) (11:30 am - 6:00 pm) Coverdell PM 6.5 hrs (after half day preschool) (11:30 am - 6:00pm) Blackhurst - PM 2.5 hrs (after full day preschool) (3:30 pm - 6:00 pm)* Coverdell PM 2.5 hrs (after full day preschool) (3:30 pm - 6:00 pm)* Monroe PM 2.5 hrs (after half day preschool) (3:30 pm - 6:00 pm) August - May $95.00/month $275.00/month $295.00/month $115.00/month *When using AM & PM Kidz Care with Full Day Preschool, there is a $20.00 discount off the combined rate. Nine (9) monthly payments will be made August-May; no payment will be due in the month of December. For further information regarding Kidz Care, please contact the Adult & Community Education office at , or visit their office at 2400 Zumbehl Road, St. Charles, MO Office hours are 9:00 am 7:00 pm, Monday-Thursday, and 9:00 am 4:00 pm on Fridays. Page 7

8 St. Charles School District Early Childhood Form APPLICATION DUE: March 4, 2014 for first round consideration of Title I funds. Applications received after this date will be considered on a first-come, first-served basis. Child s Legal Name (as it appears on birth certificate): Name child goes by: Birthdate: (must be at least 3 before Aug. 1, 2014) Sex: F M May check all that apply: Caucasian African-American Hispanic Asian Native-American Pacific Islander Is the student of Hispanic/Latino ethnicity? Yes No Child s Address: City: ZIP: Does the child live within the boundaries of the City of St. Charles School District? Yes No Mother s Name: Home Phone: Address: City: ZIP: Work Phone: Cell phone: Employer: Occupation: address: Father s Name: Home Phone: Address: City: ZIP: Work Phone: Cell phone: Employer: Occupation: address: Child lives with: Both Parents Mother Father Other Indicate any special custody agreements: Divorce/Custody Agreement Court Order for Protection The school will need copies of legal documents pertaining to custody of the child in order to appropriately handle questions regarding dismissal or other requests. Person other than parents to call in an emergency (local only): Name: Phone: Relationship to the child: Is there a language other than English spoken in the home? Y N If yes, what language? Are you currently enrolled in the Parents as Teachers program? Y N Parent Educator: Page 8

9 Do you have other children under the age of five? Y N If Yes, list name(s), birth date(s), and preschool (if applicable): Child s Name Birth Date Preschool (if applicable) Do you have school age children? Y N If Yes, list name(s), birth date(s), and school(s) of attendance: Child s Name Birth Date School Has your child had a Special Education evaluation? Y N Does your child have a current IEP? Y N Has your child had a DIAL-4 screening (given to 3-5 year olds)? Y N Which preschool class times do you prefer? (Note: Preferences are considered, but not guaranteed.) AM Preschool (8:30 am 11:30 am) PM Preschool (12:30 pm 3:30 pm) Either AM or PM Full Day (8:30 am 3:30 pm) Any Which locations do you prefer? (Note: Preferences are considered, but not guaranteed.) Please rank order (1-8) your preschool preferences and select any Kidz Care Extended Day Care options you may need. Please list N/A if a certain preschool program or location cannot be considered. Rank Order Preschool Location Blackhurst Blackhurst Coverdell Coverdell Harris Lincoln Monroe Null Page 9 Preschool Times & and Cost* AM Half Day 8:30am-11:30am $311.11/month Full Day 8:30am-3:30pm $622.22/month AM Half Day 8:30am-11:30am $311.11/month Full Day 8:30am-3:30pm $622.22/month AM Half Day 8:30am-11:30am $311.11/month AM Half Day 8:30am-11:30am $311.11/month PM Half Day 12:30pm-3:30pm $311.11/month PM Half Day 12:30pm-3:30pm $311.11/month Kidz Care AM Kidz Care PM Notes 7:00am-8:30am $95.00/month 7:00am-8:30am $95.00/month 7:00am-8:30am $95.00/month 7:00am-8:30am $95.00/month Not Available Not Available 7:00am-12:30pm $275.00/month 11:30am-6:00pm $295.00/month 3:30pm-6:00pm $115/month Enroll in AM & PM, pay $ per month! 11:30am-6:00pm $295.00/month 3:30pm-6:00pm $115/month Enroll in AM & PM, pay $ per month! Not Available Not Available Not Available 3:30pm-6:00pm $115.00/month Not Available *Payments are based upon 9 months with no payment due in December. Title funds available for qualifying students. Tuition Only. Reduced tuition available for families that qualify for free or reduced lunch. Title funds available for qualifying students. Tuition only. Reduced tuition available for families that qualify for free or reduced lunch. Title funds available for qualifying students. Title funds available for qualifying students. Title funds available for qualifying students. Title funds available for qualifying students.

10 Half Day Preschool - Applies to children attending the half day preschool program: Y N (In District Residents Only). If my child qualifies academically, I would like for Title I funding to pay for his/her half day preschool tuition. (Based upon DIAL-4 academic assessment). Y N If my child does not qualify for Title I funding, I am willing and able to pay for my child s half day preschool tuition ($2,800 per year or 9 monthly payments of $311.11). Assistance may be available through the Child Care Assistance Program offered by the Missouri Division of Social Services. Call to check your eligibility. Full Day Tuition Applies to full day preschool program: Y N I am willing and able to pay for my child s full day preschool tuition ($5,600 per year or 9 monthly payments of $622.22) Full Day Sliding Scale Tuition Applies to full day preschool program: Y N My child qualifies for free or reduced lunch (See rate chart for tuition rates) Y N I don t know if my child qualifies. To determine whether you qualify, see the attached Free and Reduced Price School Meals Application. Will you need extended day child care services (Kidz Care) for your child? Y N If yes, what times? 7:00 am - 8:30am (Blackhurst) 11:30 am 6:00 pm (Blackhurst) 3:30 pm 6:00 pm (Monroe) 3:30 pm 6:00 pm (Blackhurst) 7:00 am 12:30 pm (Monroe) 7:00 am 11:30 am (Coverdell) 3:30 pm 6:00 pm (Coverdell) How will the extended day child care services (Kidz Care) be paid? Y N N/A I am willing and able to pay the tuition for extended day child care services. Assistance may be available through the Child Care Assistance Program offered by the Missouri Division of Social Services. Call to check your eligibility. How did you learn about our program? Teacher District Website Neighbor/Friend Internet/Phone Notification Other (Explain) ALL ENROLLMENT FEES ARE NON-REFUNDABLE Parent s Printed Name: Date: Parent s Signature: Page 10

11 ATTACHMENT B Dear Parent/Guardian: LETTER TO PARENTS NATIONAL SCHOOL LUNCH PROGRAM/SCHOOL BREAKFAST PROGRAM Children need healthy meals to learn. The City of St. Charles School District offers healthy meals every school day. Breakfast costs $1.50 for all students; lunch costs $2.25/$2.50 for Elementary, $2.35/$2.60 for Secondary. Your child(ren) may qualify for free or for reduced price meals. Reduced price is 30cents for breakfast and 40 cents for lunch. 1. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all Household Size required information. Return the completed application to your child s school or: The City of St. Charles School District Administrative Offices, Chartwells School Dining Services, Dana Frank, 400 North 6 th Street, St. Charles, MO 63301, WHO CAN GET FREE MEALS? All children in households getting Food Stamps, Temporary Assistance, or the Food Distribution Program on Indian Reservations can get free meals regardless of income. Also, your child(ren) can get free meals if your household income is within the free limits on the Federal Income Eligibility Guidelines. 3. CAN FOSTER CHILDREN GET FREE MEALS? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. 4. CAN HOMELESS, RUNAWAY AND MIGRANT CHILDREN GET FREE MEALS? Please call your child s school to see if your child(ren) qualify, if you have not been informed that they will get free meals. 5. WHO CAN GET REDUCED PRICE MEALS? Your child(ren) can get low cost meals if your household income is within the reduced price limits. 6. SHOULD I FILL OUT AN APPLICATION IF I GOT A LETTER THIS SCHOOL YEAR SAYING MY CHILD(REN) ARE APPROVED FOR FREE OR REDUCED PRICE MEALS? Do not complete the attached application if you have recently received notification from your school that your child(ren) has been certified to receive free meal benefits for the school year. 7. MY CHILD S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your child s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child(ren) is eligible for the new school year. 8. I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application. 9. WILL THE INFORMATION I GIVE BE CHECKED? Yes, we may ask you to send written proof. Annually Monthly Weekly 1 $21,257 $1,772 $ ,694 2, ,131 3, ,568 3, ,005 4, ,442 4,871 1, ,879 5,490 1, ,316 6,110 1,410 For each add l person add $7,437 $620 $144

12 ATTACHMENT B (CONTINUED) 10. IF I DON T QUALIFY NOW, MAY I APPLY LATER? Yes. You may apply at any time during the school year if your household size goes up, income goes down, or if you start receiving Food Stamps, Temporary Assistance or other benefits. If you lose your job, your child(ren) may be able to get free or reduced price meals. 11. WHAT IF I DISAGREE WITH THE SCHOOL S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: Superintendent Jeff Marion, 400 North 6 th Street, St. Charles, MO 63301, MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals. 13. WHO SHOULD I INCLUDE AS MEMBERS OF MY HOUSEHOLD? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children who live with you. 14. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally get. For example, if you normally get $1,000 each month, but you missed some work last month and only got $900, put down that you get $1,000 per month. If you normally get overtime, include it, but not if you get it only sometimes. 15. WE ARE IN THE MILITARY; DO WE INCLUDE OUR HOUSING ALLOWANCE AS INCOME? If your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Exclude military combat pay received by service members during a deployment. All other allowances must be included in your gross income. If you have other question or need help, please call Dana Frank, Free and Reduced Coordinator at Sincerely, Shirley Derby, Dining Service Director Chartwells School Dining Services

13 FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION COMPLETE ONE APPLICATION PER HOUSEHOLD ATTACHMENT C PART 1. FOOD STAMP/TEMPORARY ASSISTANCE BENEFITS If any member of your household receives Food Stamps or Temporary Assistance, provide the name and case number for the person who receives the benefits below. Also complete Part 2, numbers 1, 2, and 3 for all students in the household. If no one receives benefits, fill out Part 2 completely. Name: Case Number: 0 0 PART 2. HOUSEHOLD INFORMATION 1. Name list everyone in household If Part 1 is complete list only students 2. Name of school building Name of school building for each child/student or indicate N/A if not in school 3. Grade 4. Check if a foster child legal responsibility of welfare agency or court 5. Gross income and how often it was received (weekly, every 2 weeks, 2x per month, monthly, yearly) Earnings from work before deductions Welfare, child support, alimony Pensions, retirement, social security, SSI, and VA benefits All other income Income How often Income How often Income How often Income How often 6. Check if no Income PART 3. HOMELESS, MIGRANT, OR RUNAWAY STUDENT If any student you are applying for is homeless, migrant, or a runaway contact the school/district Homeless Liaison/Migrant Coordinator at [phone number of Homeless Liaison/Migrant Coordinator] PART 4. SIGNATURE (ADULT MUST SIGN) An adult household member must sign the application. If Part 2 is completed, the adult signing the application must also list his or her last four digits of their social security number or mark the I do not have a social security number box. (See Privacy Act Statement.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get federal funds based on the information I give. I understand that the school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Sign here: Print name: Date: Address: City: Zip code: Phone number: Last 4 digits of social security number: * * * - * * - I do not have a social security number The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. PART 5. STUDENT S RACIAL AND ETHNIC IDENTITIES (OPTIONAL) Mark ethnic identity Mark one or more racial identities Hispanic or Latino Asian Black or African American Native Hawaiian or Other Pacific Islander Not Hispanic or Latino White American Indian or Alaska Native Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. DO NOT FILL OUT THIS SECTION. THIS IS FOR SCHOOL USE ONLY. ANNUAL INCOME CONVERSION: WEEKLY X 52, EVERY 2 WEEKS X 26, TWICE A MONTH X 24, MONTHLY X 12 (USE ONLY IF MULTIPLE FREQUENCY) Food Stamps/Temporary Assistance Household size: Total income: Per: Week Every 2 Weeks Twice a Month Month Year Eligibility: Free Reduced Denied Reason: Date withdrawn: Determining Official s Signature: Date Approved/Denied: Confirming Official s Signature (For verification purposes only): Date:

14 ATTACHMENT C (INSTRUCTIONS) IF YOUR HOUSEHOLD GETS FOOD STAMPS OR TEMPORARY ASSISTANCE, FOLLOW THESE INSTRUCTIONS: Part 1: If any child or adult in the household receives Food Stamps or Temporary Assistance benefits, provide the name of the person receiving the benefits and the case number. Food Stamp/Temporary Assistance case numbers are a ten-digit number; the first two digits currently are 00 and are printed on the application. A 16-digit Electronic Benefit Transfer (EBT) Card number is NOT acceptable. Currently, an EBT number starts with If you do not know your Food Stamp/Temporary Assistance case number, call the local Family Support Division, Social Services office. Part 2: List Student(s) name(s), school building and grade. Part 3: Skip this part. Part 4: Sign the application. The last four digits of a social security number are not required. Part 5: Indicate ethnic and racial identity if you choose to do so. IF ANY STUDENT YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY CONTACT THE SCHOOL/DISTRICT HOMELESS LIAISON/MIGRANT COORDINATOR. IF YOU ARE APPLYING FOR A FOSTER CHILD OR A HOUSEHOLD WITH A FOSTER CHILD(REN), FOLLOW THESE INSTRUCTIONS: Part 1: Skip this part. Part 2: List student(s) name(s), school building and grade. Check the box if the student is a foster child (legal responsibility of welfare agency or court). Provide the amount of the foster child s personal use income or earnings. Write 0 if the foster child has no personal use income. List all non-foster children in the household, name of school building, and grade and any income they receive. If there are non-foster children in the household, follow directions in All Other Households, Part 2, columns 1, 5 and 6. Part 3: Skip this part. Part 4: If the form is only for foster children, the last four digits of the social security number of the adult signing the form are not necessary. If non-foster children are in the household, list the last four digits of the social security number of the adult signing the form or check the box if they do not have a social security number. Part 5: Indicate ethnic and racial identity if you choose to do so. ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: Part 1: Skip this part. Part 2: Follow these instructions to report total household income from last month: Column 1 Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends) including yourself. Attach another sheet of paper if you need more room to list all household members. Column 2 Name of School Building: Indicate the school building each student attends. Column 3 Grade: Indicate the grade level of each student. Column 4 Foster Child: If any student is a foster child (legal responsibility of a welfare agency or court), check the box. Column 5 Gross income last month and how often it was received: Next to each household member s name list each type of income received last month, and how often it was received. For example, Earnings from work: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person received it (weekly, every other week, twice a month, or monthly). List the amount each person got last month from welfare, child support, alimony; pensions, retirement, social security; and all other income in the appropriate categories. In the other income column, include Worker s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, and ANY OTHER INCOME. Report net income for self-owned business, farm, or rental income. Next to the amount, write how often the person received it. If you are in the Military Housing Privatization Initiative do not include this housing allowance. Exclude military combat pay received by service members during a deployment. Column 6 Check if no income: If the person does not have any income, check the box. Part 3: Skip this part. Part 4: An adult household member must sign the form and list the last four digits of the social security number of the adult signing the form, or mark the box if he or she doesn t have a social security number. Part 5: Indicate ethnic and racial identity if you choose to do so.

15 ATTACHMENT G1 REQUEST FOR INFORMATION (Complete one form per family) Please answer the question below by checking the appropriate box. The following information is a request adopted by the General Assembly in 2010 requiring school districts to determine whether or not all children in a family have health insurance. Does each child in your family have health care insurance? YES NO MO HealthNet (Medicaid) is considered health care insurance. If NO is checked the school district will provide a MO HealthNet for Kids application for the family. Completion of this form is not a condition of determining meal eligibility. The Free and Reduced Price Meals Family Application will be reviewed regardless of your response to this Request for Information. Submit this request with your Free and Reduced Price School Meal Family Application or return to your school/school district. Printed name of parent/guardian: Mailing Address: City: State: Zip Code:

2015-2016 APPLICATION St. Charles School District Early Childhood Preschool Program

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