Lake School District Preschool Registration
2021-2022 School Year
Pre-Registration Form for
Typically Developing Preschoolers
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Child First Name *
Child Middle Name *
Child Last Name *
Birth Date (Month/Day/Year) *
MM
/
DD
/
YYYY
Gender *
Address *
Home Phone *
Session Preference *
Child Lives with *
Legal Custodial Mother/Guardian - Name *
Legal Custodial Mother/Guardian - Address *
Legal Custodial Mother/Guardian - Home Phone *
Legal Custodial Mother/Guardian - Cell Phone *
Legal Custodial Mother/Guardian - Employer *
Legal Custodial Mother/Guardian - Business Phone *
Legal Custodial Father/Guardian - Name *
Legal Custodial Father/Guardian - Address *
Legal Custodial Father/Guardian - Home Phone *
Legal Custodial Father/Guardian - Cell Phone *
Legal Custodial Father/Guardian - Employer *
Legal Custodial Father/Guardian - Business Phone *
Will your child be 4 years old by October 1, 2021? *
If yes, you may qualify for a Grant placement into the program as long as your income is below 200% on the Federal Income Guidelines.  If your child does not meet the age requirement, your child may only be considered for our Non Grant program, paying full tuition (ages 3-5), unless your child is identified as needing specialized education.  In that case, they can be placed into our preschool Special Education program, once identified and they reach their third birthday.
2021 FEDERAL POVERTY GUIDELINES
1.   Number of members in your household including yourself: *
2.  Enter your gross family income before deductions: *
3.  What program do you feel your child would be eligible for according to the guidelines listed? *
2021 FEDERAL POVERTY GUIDELINES
Do you have any concerns regarding your child's development in any of the following areas, if so please explain:
Vision concerns (crossed eye) *
If yes, please explain concern:
Hearing concerns *
If yes, please explain concern:
Language concerns *
If yes, please explain concern:
Socialization concerns *
If yes, please explain concern:
Frequent ear infections *
If yes, please explain concern:
Any medical diagnosis *
If yes, please explain concern:
Mobility concerns *
Required
If yes, please explain concern:
Significant injuries *
If yes, please explain concern:
Hospitalizations *
If yes, please explain concern:
Other health concerns *
If yes, please explain concern:
Have had chicken pox *
If yes, please explain concern:
Has your child received any therapeutic services (e.g. speech/language, counseling, occupational therapy)? *
If yes, please list types of services, length of services and by whom.  Please email copy of report(s) if available to mwilburn@lakeschools.org
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