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Southwest Preschool Application
Date: _________
Assurance of Confidentiality: The information on this form is being requested on a voluntary basis. The information you provide will help us to deliver or direct services most appropriate for your family’s needs. Some of the information may be used to help plan national program initiatives. If you prefer not to provide some of the information, it will not affect the services we try to deliver. However, some information is required for eligibility determination. All information will be held in strict confidence.
Section 1: Applicant Name: (child)
Last: ______________________ First: ___________________ Middle: ______________
Gender: ___Male ___ Female Date of Birth: _______________ SS# _____________
Age: ________
Race/Ethnicity: __W __B __NA __H __A __PI __Other____________
Was he/she born prematurely? ____yes ___no How many months? ______________
Does your child currently have an IFSP or IEP? _____________________________
Section 2: Primary supporting adult(s) names(s)
Last: ____________________ First: _____________________
__ biological parent __ adoptive parent __step parent __foster parent __grandparent __ legal guardian __ other _____________
Last: ____________________ First: _____________________
__ biological parent __ adoptive parent __step parent __foster parent __grandparent __ legal guardian __ other _____________
Living Address _________________________ City _______________ State/zip________
Mailing Address _______________________ City ________________ State/Zip_______
Home phone ________________ Work phone ____________ Cell phone ___________
Is this person employed or in school? (specify) __Employed __Full-time __part-time __unemployed
__ In school __Full-time __part-time
Highest level of education completed:
__G9 or less __G10 __G11 __G12 __HSG __GED __Ass.Deg __Bach Deg __Mas. Deg __College training Cert. __Some college
What is the primary language spoken at home?(specify) Primary: _________________
Secondary: ________________
Is the child applying part of a dual custody family? __No __Yes (child lives in the physical custody of more than one parent/guardian during the enrollment year)
Section 3: Application information-Family Composition
Family type: __One Parent __Two Parent __Foster __Non-Parent
Number of adults in Family: ___ Number of Children: ___ Total number in family: ___
Section 4: Additional Children in the Family:
Name: ________________________ Date of Birth: __________________ Age:_______
Name: ________________________ Date of Birth: __________________ Age:_______
Name: ________________________ Date of Birth: __________________ Age:_______
Name: ________________________ Date of Birth: __________________ Age:_______
Name: ________________________ Date of Birth: __________________ Age:_______
Section 5:
Please fill out the attached application for free and reduced lunch. Students who qualify are given priority over students who do not. If you don’t fill out the form it will be assumed your family does not qualify.
Parent/Guardian Signature: ______________________________________________
Tell Me About Your Child
Name ___________________________ Age _____ Date of Birth _______________
I love ________________________________________________________________________
I don’t like ____________________________________________________________________
Please tell me about your child’s favorite activities, books games etc.
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
How does your child get along with other children?_________________________________
_____________________________________________________________________________
Does your child have any nervous habits? ________________________________________
Does your child have any allergies? ______________________________________________
Do you have any concerns about your child’s development? _________________________
_____________________________________________________________________________
Is your child on an IEP (Individual Education Plan)? ______________________________________
Is there anything else you would like me to know about your child?
____________________________________________________________________________
____________________________________________________________________________