2020-2021 Peer Model Application
Thank you for your interest in the Blue Valley Early Childhood Program!  Please complete the application below for each child you wish to enroll as a peer.  If you have concerns about your child's development, please contact the early childhood office at 913-624-2912 or click here:  https://district.bluevalleyk12.org/ParentsAndStudents/Pages/EarlyChildhoodSpecialEducation.aspx

To be considered for enrollment, children must meet ALL criteria for peers as follows:
- must be 3 years old prior to attending
- must not be eligible by age for kindergarten (5 on or before 8/31/2020)
- must be independent with toileting
- must speak English fluently
- must not be eligible to receive special education services (including speech and language services)

Please note Peer programs are not available at every school and enrollment is limited. To the greatest degree possible, children will be placed at a location/in a classroom with other children from your neighborhood school.

Children who are 3 years old and will turn 4 during the school year (not eligible to attend kindergarten in 2021-2022) will be placed in the AM

Children who are 4 years old and will turn 5 during the school year (eligible to attend kindergarten in 2021-2022) will be placed in the PM.

For more information about the peer program, please click here:
 https://district.bluevalleyk12.org/ParentsAndStudents/Pages/EarlyChildhoodServices.aspx

At the end of this application there will be two online screening questionnaires, please note that both questionnaires must be completed in order for the application to move forward in the process.

Please note, transportation is NOT available for Peer Models.

Sign in to Google to save your progress. Learn more
Email *
Child's First Name: *
Child's Last Name: *
Child's Date of Birth: *
MM
/
DD
/
YYYY
Child's Age *
Child's Gender: *
Child's Race: *
Child's Ethnicity *
Required
Street Address: (you MUST include any Apartment Number in order to verify address) *
City *
State: *
Zip Code: *
Child's Birth Country: *
Home Phone: (Include Area Code) *
Name of Preschool Currently Attending:
Length of time at this preschool?
How did you hear about us? *
Which School Year are you applying for? *
What language did your child first learn to speak? *
What language(s) are spoken at home? *
What language do you speak with your child? *
What language(s) do the adults regularly present in the home speak while in the presence of the child? *
Which language do you prefer to speak? *
My child is independent with toileting: *
If your child is "not yet" or "sometimes" independent with toileting, please explain: *
Is  your child receiving any type of services through Blue Valley School District or an outside agency? (Speech Therapy, Occupational Therapy, etc.) *
Has your child been screened, evaluated, or received special education services? *
If yes, please give dates and describe services provided, if any: *
Parent's First Name *
Parent's Last Name *
Parent's Gender: *
Parent's Email Address: *
Parent's Home Phone (with Area Code): *
Parent's Cell Phone (with Area Code): *
Parent's Work Phone (with Area Code): *
Parent's Employer: *
Additional Parent's First Name:
Additional Parent's Last Name:
Additional Parent's Gender:
Clear selection
Additional Parent's Email:
Additional Parent's Home Phone (with Area Code):
Additional Parent's Cell Phone (with Area Code):
Additional Parent's Work Phone (with Area Code):
Additional Parent's Employer
Sibling's First Name:
Sibling's Last Name
Sibling's Age:
Sibling's Grade:
Sibling's School:
Additional Sibling's First Name:
Additional Sibling's Last Name:
Additional Sibling's Age:
Additional Sibling's Grade:
Additional Sibling's School
Additional Information or Comments:
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Blue Valley School District. Report Abuse
Google Forms