Chimacum School District

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TRANSITIONAL KINDERGARTEN APPLICATION

for September 2023 - June 2024

Email *

Child's First Name *

Child's Last Name *

Child's Age *

Child's Birth Date *

YYYY

Parent/Guardian First Name *

Parent/Guardian Last Name *

Phone Number

Email *

Street Address

Zip Code *

Mailing Address (if different from street address) *

How did you hear about the program? *

Does your child speak another language besides English? *

Yes

Has your child ever been offered placement or enrolled in a Head Start/ECEAP program? *

Yes

Has your child ever been enrolled with a child care provider or daycare?

Yes

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If so, please specify name of center or location. *

If so, please confirm last day attended. *

YYYY

Has you child been enrolled in another preschool program? *

Yes

If so, please specify name of center or location. *

Is your child cared for by family, friends or neighbors? *

Yes

Other considerations for enrollment:

(check all that apply)

Has your child not yet had a preschool experience?

Does your child have an Individualized Education Plan (IEP)?

Are you concerned about your child's social skills or learning skills?

Has your child had limited or no opportunities to play with other children?

Is your family experiencing inadequate housing or homelessness?

Has your child participated in birth to three early intervention services?

Has your child participated in a private preschool program?

Has your child participated in Speech or Language Services?

Has your child participated in occupational or physical therapy services?

Other:

Required

What is the best way to contact you? *

Phone

If you need an interpreter, what language? If so, please specify below.

Submit

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