_______________
Today’s Date

Child’s Name: _________________________________ ______________
                          Last     First     Middle                               Birth Date

Name child will be called at school: ______________________ Male/Female

Child’s Social Security #___________________ Telephone #___________

Address: _____________________________________________________
                Street           Apt#           City           State               ZIP

Parent/Guardian’s Name: ________________________________________
                      Address: _____________________________________
                      City/State: ______________________ZIP____________

My child will be 3years old /   4years old /   5years old September 30,2005
                                (Please circle correct age.)
Please circle your school choice:
Baxter     Jere Whitson     Park View     Uffelman     Cane Creek     Sycamore
(The recommended choice is where your child will attend Kindergarten.)

The following information is needed to determine your child’s
eligibility for this program:
_______________________________     ____________________
Printed Name of Adult Signer                         Adult’s Social Security#

Total Number in Household _____

Food Stamp or AFDC Case#                               _______________
Gross Monthly Earnings (Before Deductions):        _______________
Monthly Welfare, Pensions, Alimony,
Unemployment, Child Support, Social Security:      _______________
Any Other Cash Income:                                       _______________

TOTAL FAMILY INCOME:                               _______________

Child Lives With:
Mother     Father     Grandparents     Guardian
Other _________ (Circle all that apply)

Names of Brothers or Sisters

Name_________________________ Grade______ School_______
         _________________________           ______           _______
         _________________________           ______           _______
         _________________________           ______           _______

Is your child currently enrolled in Head Start? Yes No

Is your child currently enrolled in Day Care? Yes No
          __________________________________________
                                        Name of Daycare
Please describe below any special circumstances that might enhance your
child’s eligibility for this pre-school program:

**You may be asked to provide documentation to verify the above information.
                                      ____________________________________
                                      Signature of Adult Household Member

**Before your child is placed in our preschool program a very brief assessment may be done to determine your child’s strengths and areas of need.