Adams Central Early Childhood Center

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Our goal is to provide a no-cost preschool experience to every 3 and 4 year old student who resides in the Adams Central District. Some years we have a waiting list. If this is the case, students will be accepted in the following order of priority:

1) Students with disabilities are guaranteed a placement, as required by law.

2) Students not yet verified but who are at-risk will then be considered.

3) Students who will enter Kindergarten the following year (age 5 by 7/31/2024).

4) Students who will enter Kindergarten in August 2025 (age 5 by 7/31/2025).

5) Non-resident children.

Applications will be processed in the order in which they are received.

Email *

Student Last Name *

Student First Name *

Please check your class preference. Every attempt will be made to grant your request, however, students will be placed depending on student/teacher ratio & other demographic information. *

AM class (anticipated time 8:00 a.m. - 11:15 a.m.)

PM class (anticipated time 11:45 a.m. - 3:00 p.m.)

All-day class (anticipated time 8:00 a.m. - 3:00 p.m.; For students who will be entering kindergarten August 2024.

Student Date of Birth *

YYYY

Student Age *

Student Gender *

Female

Male

Do you live in the Adams Central School District *

Yes

Unknown

Street Address *

City *

State *

Zip *

Father's Name (first & last name) *

Father's Phone # (xxx-xxx-xxxx) *

Father's address *

Father's email address *

Father's Employment Status *

Full-time

Part-time

Temporary

Unemployed

Father's Employer (if unemployed list NA) *

Father's Employer's Phone # *

Father completed High School? *

Yes

Mother's Name (first & last name) *

Mother's Address *

Mother's Phone # (xxx-xxx-xxxx) *

Mother's email address *

Mother's Employment Status *

Full-time

Part-time

Temporary

Unemployed

Mother completed High School *

Yes

Mother's Employer (if unemployed list NA) *

Mother's Employer's Phone # *

Students Race/Ethnicity *

Asian

Black or African American

American Indian

Alaska Native

Hispanic/Latino

White

Required

Language of choice spoken in the home *

Which of the following descriptions best fits the child's family *

Two Parent Family

Single Parent Family

Teen Parent

Has the child attended another preschool? *

Yes

If yes, name of Preschool (s)

Does anyone in the immediate family have a disability? *

Yes

If yes, please answer

Parent

Student

Sibling

Clear selection

Does the child receive special education services or currently have an IEP/IFSP? *

Yes

Does the child have Medicaid? *

Yes

This child was born to teenage parents. *

Yes

Required

Was the child born premature (38 weeks or less) OR at a low birth weight? *

Yes

If yes, please specify

Please estimate your child's cognitive abilities: *

Significant Cognitive Struggles

Cognitively gifted

Please estimate your child's self-help and self-care skills: *

Total Dependence (adult supports for all areas)

Age appropriate independence skills (potty trained, dresses self, etc.)

Please estimate your child's communication skills: *

Nonverbal, Limited Eye contact, etc.

Age appropriate sounds, using verbal and nonverbal communication

Please estimate your child's behavioral and social skills: *

Requires 1:1 support

Follows directions, participates in large and small groups, regulates emotions, etc.

If yes, please explain

Additional Comments

Parent Signature (type in name of parent name completing this form) *

Submit

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