GSRP Pre-Screen Form

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Parents complete this form if you are interested in free preschool for you 4 year old!

* Indicates required question

Child's Birth Date *

MM

/

DD

/

YYYY

Child's Full Name *

Your answer

Child's Sex *

Female

Male

Child's Street Address, City, and Zip Code *

Your answer

Phone Number *

Your answer

Alternate Phone Number

Your answer

Parent E-mail *

Your answer

Parent/Guardian's Name *

Your answer

Parent/Guardian's Name

Your answer

Number of ALL (self, children, and other adults) household members for which you are financially responsible for: *

Your answer

Gross Income and Frequency (i.e. weekly, bi-weekly, 2 times/month, monthly) *

Your answer

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