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ESA Grant Eligibility Form (English)
State of Utah, Department of Workforce Services, Office of Childcare
Disclaimer: Filling out this grant eligibility application does not automatically guarantee acceptance nor enrollment into ICSD Preschool's Program.
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* Indicates required question
Email
*
Your email
Child's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Parent(s) Name
*
Your answer
Physical Address (school boundary indicator)
*
Your answer
Phone Number
*
Your answer
Boundary School
*
South Preschool (638 W 500 S)
Three Peaks Preschool (1521 Midvalley Road)
Is your child eligible for Kindergarten (5 years-old on or before September 1st, 2021)?
*
*If you selected no, please continue to complete the form*
Yes
No
Is your child eligible for free or reduced lunch?
*
Yes
No
I don't know
Is your child an English Learner (learning English as a second language)?
*
Yes
No
I don't know
Select the number range of Risk Factors that apply to your child:
*
0
1-2
3-5
6-8
9-10
11-12
Affirmation: I certify that the above information is true and accurate to the best of my knowledge.
*
Yes
Disclaimer: Filling out this grant eligibility application does not automatically guarantee acceptance nor enrollment into ICSD Preschool's Program.
*
I understand
Parent Signature
*
Typing your name will act as an electronic signature
Your answer
Date
*
MM
/
DD
/
YYYY
Submit
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This form was created inside of Iron County Schools.
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