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USD #431 Preschool Application Form 2021-2022
Child Information
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* Indicates required question
Student's Name (First, Middle, Last)
*
Your answer
Date of Birth
*
Your answer
Gender
*
Female
Male
Street Address
*
Your answer
City, State, Zip
*
Your answer
Mailing Address
*
Your answer
City, State, Zip
*
Your answer
Home Phone
*
Your answer
Automated Message Number
*
Your answer
Email Address
*
Your answer
Ethnicity/Race Information: Hispanic
*
Yes
No
Race:
*
American Indian
Asian
Black/African American
Native Hawaiian/Pacific Island
White
Primary Language Spoken in the Home:
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English
Other
Child Lives With:
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Parents
Father
Mother
Other/Foster
Does your child qualify for benefits in the School Lunch Program?
*
Yes
No
Are you working with SRS? If so, do you have an assigned case worker?
*
Yes
No
Is your child receiving any special services? (speech, therapy, learning disabilities, other)
*
Yes
No
Does your family qualify as migrant?
*
Yes
No
Is your child developmentally or academically delayed based on assessments?
*
Yes
No
Parent Information
*
Father
Name:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Age when child was born:
*
Your answer
Address:
*
Your answer
Home/Cell Phone Number:
*
Your answer
Employer:
*
Your answer
Work Phone Number:
*
Your answer
Highest Education Completed:
*
9th Grade
10th Grade
11th Grade
12th Grade
Did not complete High School
GED
College
Parent Information:
*
Mother
Name:
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Age when child was born:
*
Your answer
Address:
*
Your answer
Home/Cell Phone Number:
*
Your answer
Employer:
*
Your answer
Work Phone Number:
*
Your answer
Highest Education Completed:
*
9th Grade
10th Grade
11th Grade
12th Grade
Did not complete High School
GED
College
Parents' Marital Status
*
Married
Separated
Divorced
Widowed
Single
Name and Ages of siblings in the household:
*
Your answer
Parent/Guardian Signature (type please):
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Morning or Afternoon Class Preference
*
Morning
Afternoon
THIS SECTION COMPLETED BY OFFICE STAFF: ASSIGNED SESSION
MORNING
AFTERNOON
Clear selection
THIS SECTION COMPLETED BY THE SCHOOL NURSE
Current Immunizations
Certified Birth Certificate
Current Physical
Clear selection
SCREENING NEEDED:
IEP
BIRTH VERIFICATION
Clear selection
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