Welcome to the Council Bluffs District Infant/Toddler Application for the 2023-2024 school year!
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Email *
Student First Name *
Student Last Name *
What is your child's date of birth/Due Date? *
MM
/
DD
/
YYYY
What is your child's gender? *
How many people are currently living in the household? *
What was your total household income for 2022? (This information is needed for our grants and can be found on line 11 of your 2022 federal 1040 tax return form.) *
What is the Primary Language spoken by the child? *
What is the Primary Language spoken by the parent(s)? *
Contact information for: *
First Name *
Last Name *
Address *
City *
State *
Zip Code *
Primary Contact Number *
Email: *
Schooling completed by this adult: *
Employment Status of this adult: *
Contact Information for:
Clear selection
First Name
Last Name
Address
City
State
Zip Code
Primary Contact Number
Email:
Schooling completed by this adult:
Clear selection
Employment Status of this adult:
Clear selection
Who has custody of this child? *
Does the child have Health Insurance? *
Required
Do the parents have Health Insurance? *
Is there a current Order of Protection or No Contact Order which concerns this student? *
Does your family qualify for Child Care Assistance? *
Will you be using your Child Care Assistance to pay for programming? *
If you are not planning to use Child Care Assistance to pay for programming, would you be willing to  pay tuition? *
Do you have other children already in school? *
If Yes, what school(s) do they attend? *
Required
Does your child have any of the following? *
Required
Please list any additional concerns or issues that are affecting your child and/or family:
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