Lowndes County School District. Pre-Kindergarten Application

Transcription

1 Welcome to Pre-K

2 Lowndes County School District Pre-Kindergarten Application Pre-Kindergarten: Applicant must meet the MS age requirements for the school year. (4 by September 1) A certified copy of your child s birth certificate A copy of your child s Immunization Compliance Form (Form 121) Up-to-date Two proofs of residency: o Mortgage/lease agreement o Electric/gas/telephone bill (land-line only) o Driver s License o Voter Registration Card Proof of income *The same name and address MUST be on both documents. Deadline: May 15, 2014 Return applications to Caledonia Elementary School, New Hope Elementary School, West Lowndes Elementary School, or Lowndes County Schools District Office Application MUST be received by 4:00 PM, May 15, 2014 *Only the parent or legal guardian can register a child for school. Please PRINT or TYPE Student s Name: (Last/First/Middle) Street Address: City Zip Mailing Address: (if different) Home Phone: Cell Phone: Work Phone: Date of Birth: Gender: MALE FEMALE Race: American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Other Pacific Islander White or Caucasian Other Special Needs: Yes No If YES, explain: School Applying for: (Choose Only One) Caledonia Elementary West Lowndes Elementary New Hope Elementary Are you interested in the tuition based program in the event that you are not selected for the nontuition Title 1 preschool program? I am applying for placement of my child at the school indicated above. I understand that the information provided by me on this application will be checked for accuracy, and that false information will disqualify the application. Signature of Parent or Legal Guardian Date 2

3 Lowndes County School District Pre-Kindergarten Questionnaire The following information is needed to assist the Lowndes County School District in the selection process for Pre-K program. All information is confidential. Your child will not be considered for selection until you have completed and returned the questionnaire by the May 15, 2014, deadline. Child s Name: Gender: Male Female Parent/Guardian s Name: Mailing Address Child lives with: (check all that applies) Both Parents Mother Father Maternal Grandparents Paternal Grandparents Other (describe) Parent/Guardian Marital Status: Single Married Divorced If divorced, who has custody? Mother Father Both Other, explain Family Unit: List only parents/guardians living in the child s 1. Mother/Guardian s Name: Education: College, High School, GED, etc. Employer Full Time Part Time Unemp 2. Father/Guardian s Name: 3. Other Adult s Name: 4. Other Adult s Name: 3

4 Family Unit List names of other children living in the Gender Age Family Unit List names of other children living in the Gender Age Total number in your family (A family consists of those persons living in the household who are related by blood, marriage, or adoption and supported by the income of the child s parent or guardian.) Family Receives: TANF Food Stamps (EBT) WIC Social Security CCDF (child care certificates) Child Support Unemployment Energy Assistance Public Housing Veterans Assistance (VA) Family Income: Most recent monthly income (Documentation Required) Below 11,000 27,000 29,999 11,000 14,999 30,000 33,999 Note: Most recent income information for all adults in the 15,000 18,999 34,000 37,999 19,000 22,999 38,000 42,999 23,000 26,999 Over 43,000 4

5 Has your child participated in Head Start? Yes No Private Day Care? (Name) Has your child participated in Even Start? Yes No Special Concerns: Foster Care Migrant Family Homeless Other, explain Does your child wear glasses? Yes No Does your child wear a hearing aid? Yes No Is English the primary language in your household? Yes No Do you or anyone in your household speak another language? Yes No If yes, what language Does your child speak another language? Yes No If yes, what language Child s Characteristics. Does your child have any of the following conditions? YES NO Have any of the conditions checked been diagnosed? If yes, you must complete the information below. Mental Retardation Hearing Impairment Visual Impairment Speech/Language Impairment Emotional/Behavioral Disorder Health Impairment Orthopedic Impairment Learning Disabilities Autism Traumatic Brain Injury Other Impairment 1. Doctor/Agency s Name Condition: Address: City, State & Zip Telephone: Date last seen: 2. Doctor/Agency s Name Condition: Address: City, State & Zip Telephone: Date last seen: Complete Release of Information form for each doctor or agency listed. 5