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2021-2022 Watervliet GSRP Preschool Eligibility Determination
(Child Intake Form) Please complete ONE per CHILD
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* Indicates required question
Email
*
Your email
Email address
In what Early Childhood program is your child currently enrolled?
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Your answer
How did you hear about Early Child Education in your community?
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Your answer
Child's Name:
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Your answer
Male or Female
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Male
Female
Date of Birth:
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MM
/
DD
/
YYYY
Parent/Legal Guardian(s)
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Your answer
Street Address:
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Your answer
City:
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Your answer
School District of Residence:
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Your answer
Phone # (Home/Cell/Work)
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Your answer
Alt. Phone #: (Home/Cell/Work)
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Your answer
Email:
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Your answer
Is there an IEP/IFSP currently in place for this child?
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Yes
No
What concerns do you have about your child's speech, language or development?
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Your answer
Annual Gross Income:
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Your answer
# of Family in the Home:
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Your answer
Foster Child?
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Yes
No
Homeless?
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Yes
No
SSI Disability?
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Yes
No
Cash Assistance?
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Yes
No
Language?
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English
Spanish
Other
Notes/Special Instructions
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Your answer
Proof of Residency
*
Option 1
Drivers License
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Your answer
W-2 or 2 months of pay stubs
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W-2
2 months pay stubs
Birth Certificate
*
Yes
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