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Early Childhood Program Application
The Hampden-Wilbraham Regional School District is pleased to once again offer integrated early childhood programs for the
2023/2024
school year, consisting of either a morning or an afternoon session for the children of both towns.
UPDATE - THE APPLICATION FOR THE UPCOMING 2024/2025 SCHOOL YEAR WILL BE POSTED SOON
!
Please contact Student Services at 413-279-3801 if you have any questions.
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* Indicates required question
Email
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Your email
Today's Date:
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MM
/
DD
/
YYYY
Student's legal name (First, middle, last):
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Your answer
Student's gender
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Male
Female
Date of Birth:
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MM
/
DD
/
YYYY
Place of birth (city, state)
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Your answer
Address (Include street and town) - student must be listed on town census
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Your answer
Parent/Guardian name:
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Your answer
Parent /Guardian telephone #:
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Your answer
Parent/Guardian e-mail:
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Your answer
Parent/Guardian name:
Your answer
Parent/Guardian telephone #:
Your answer
Parent/guardian e-mail:
Your answer
Siblings name(s), age(s) and school(s)
Your answer
Please indicate your choice of program
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Half Day Early Childhood Program (M-F) - Morning Session
Half Day Early Childhood Program (M-F) - Afternoon Session
Either
How would you describe your child socially?
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Has a lot of friends
Prefers one or two others
Plays mainly with brothers or sisters
Prefers to play alone
Where does your child like to play?
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Prefers outdoor activities
Prefers indoor activities
Likes both equally
Is your child able to..
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Dress self completely
Put all clothes on, but is unable to button or zip
Put on easy articles of clothing (e.g. pajamas, coat)
Does your child..
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Speak clearly most of the time
Have some difficulty making self understood
Struggle to be understood, especially by those outside of family
How does your child communicate?
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Speaks in long sentences and paragraphs
Uses mostly two to three word sentences
Uses mostly single words
Describe your child (check all that apply)
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Friendly
Shy
Cooperative
Independent
Stubborn
Difficult to handle
Required
Which best describes your child?
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Frustrated easily
Extremely quiet
Very easy going, unruffled
Independent, likes his/her own way
Has your child experienced ear infections?
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No
Yes (infrequent - two to three per year)
Yes (frequent - four or more per year)
Any vision concerns?
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Vision is fine
I question whether my child sees well
Child is under doctor's care
How is your child in new situations or with new people?
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Your answer
Any previous school experience or early intervention services (if yes, please indicate where or by whom, how long and services received)
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Your answer
Is there any other information you would like us to know about your child?
Your answer
Are there any questions we can answer for you?
Your answer
A copy of your responses will be emailed to the address you provided.
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