2020-21 PreK Initial Registration
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E-postadresse *
Name of Person Completing form *
Student First Name *
Student Last Name *
Student Date of Birth *
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How old will your child be on August 15, 2021? *
Gender *
Zoned School *
Other Children in Household Attend: *
Parent/Guardian Name(s) *
Parent/Guardian Zip Code *
Parent/Guardian City *
Parent/Guardian(s) Mailing Address *
Parent/Guardian(s) Primary Phone *
Parent/Guardian(s) Secondary Phone
Parent/Guardian(s) Email Address *
Did your family participate in any of the following during the 2020-21 school year? If so, your child may automatically qualify for PreK. You will NOT be asked to provide proof of household income but will be required to sign to verify your participation in the program(s) below: *
Obligatorisk
Total Number Living in Household during 2020-21 School Year (include the total number of all children and adults, regardless of relationship to PreK child) *
Total Household 2020 Income (must include ALL income for ALL household members) *
Please list the name, age, and the relationship of all individuals who live in the same home as the student: *
Does your family live with another family (to include grandparents or other relatives)? *
If your family lives with another family, is it due to your loss of housing, an economic hardship, or a similar reason?
Opphev valget
If your family lives with another family, how long have you lived together?
Were there any difficulties with the pregnancy or delivery of this child? *
If there were difficulties, please describe:
Were there any concerns noted after delivery? *
If there were concerns after delivery, please describe:
Please describe any concerns with the child's early development:
Please mark any of the following which were late in developing: *
Obligatorisk
Did any members of the child’s immediate family (parents, siblings, grandparents, cousins, etc.) have difficulty in school? If so, please describe:
What is the highest grade completed by the child's mother? *
What is the highest grade completed by the child's father? *
Has the child ever been hospitalized? If so, please provide age of hospitalization and reason:
Do you have concerns with any of the following areas of your child's development: *
Obligatorisk
Is there a history of any of the following (mark all that apply): *
Obligatorisk
Has your child attended a preschool or Head Start program? *
Does your child receive any therapies or interventions? *
Are there any home/community issues that may be interfering with the child’s ability to learn? (i.e. divorce, death in the family, court involvement, etc.) If so, please describe:
Is there anything else we should know about your child?
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Dette skjemaet ble opprettet på Houston County BOE. Rapporter uriktig bruk
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