State Funded Registration Request 2022-2023 (Wait List)

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Please complete this Registration Request Form to put your child's name on the Wait List for State-Funded/Head Start preschool registration.

Eligibility is based on state and federal income guidelines. Provide us with ALL required information. You may also leave us comments at the end. You will receive an automated confirmation of your submission from Google Docs.

Based on the information you provide through this form, the PUSD Preschool Department will make an appointment for you submit documentation and determine your eligibility for state-funded preschool services. Appointments may be held in person, virtually via Zoom conference or via telephone.

Please allow for up to 10 business days after completing this form to receive your initial contact from the PUSD Preschool Department.

ALL INFORMATION IS KEPT CONFIDENTIAL.

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Διεύθυνση ηλεκτρονικού ταχυδρομείου *

Parent First Name *

Parent Last Name *

Phone *

Address (including zip code) *

Child's First Name *

Child's Last Name *

Child's birth date (NOTE: Children must be either 3 or 4 years old on or before 2/2/2023). *

ΜΜ

ΗΗ

ΕΕΕΕ

Site - First Choice (choose only one) *

Any 3 hour class

Any 6 hour class

Del Norte 3 hour

Rolling Hills AM 3 hour

Los Penasquitos 6 hour

Pomerado 6 hour

Sundance 6 hour

Valley 6 hour

Site - Second Choice (choose any that you would be willing and able to attend)

Any 3 hour class

Any 6 hour class

Del Norte 3 hour

Rolling Hills AM 3 hour

Los Penasquitos 6 hour

Pomerado 6 hour

Sundance 6 hour

Valley 6 hour

Total MONTHLY Income BEFORE taxes from all sources (wages, spousal/child support, cash aid, housing allowance, self-employment income), *

Family Size - How many are living in your household? *

Do you or someone in your family receive TANF? *

Yes

Do you or someone in your family receive SSI? *

Yes

Do you or someone in your family receive SNAP? *

Yes

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