Glen Rose Pre-Kindergarten Registration

Glen Rose Pre-Kindergarten Registration

2023-2024 School Year
Child's Name

First NameMiddle NameLast Name
Primary Guardian Information
Primary Guardian (with most contact with child)

First NameMiddle NameLast Name
Date of Birth
Gender
Ethnicity
Relationship to Child
Disabled
Cell #
Home #
Work #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language
Secondary Language
Employment Status (FT, PT)
Employer Name
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
# of Hours Per Week
Medical Insurance
Education Level
Completion Date
If attending school, where?
# of Semester Hours
Current Housing

RentOwnHomeless
Receive WIC

YesNoPreviously
Has your family moved in the last 24 months?

YesNo
Food Stamps?

YesNo
Marital Status
Secondary Caregiver Information
or

Single Parent Household
Secondary Caregiver

First NameMiddle NameLast Name
Date of Birth
Gender
Ethnicity
Relationship to Child
Disabled
Cell #
Home #
Work #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language
Secondary Language
Employment Status (FT, PT)
Employer Name
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
# of Hours Per Week
Medical Insurance
Education Level
Completion Date
If attending school, where?
# of Semester Hours
Current Housing

RentOwnHomeless
Receive WIC

YesNoPreviously
Has your family moved in the last 24 months?

YesNo
Food Stamps?

YesNo
Marital Status
Household Information
*Number in Family (The number of immediate family members living in house. (Parent, Guardian,student, Siblings):
Estimated household income (Proof is required for enrollment)
Number in Household (The total number of people living in the house):
List the name and relationship to the child enrolled of all family members in the household including student:

	Name	Relationship to Child	Education
Family Member #1
Family Member #2
Family Member #3
Family Member #4
Family Member #5
Family Member #6
Family Member #7
Family Member #8
Family Member #9
Family Member #10

Child Information
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security #
Gender
Ethnicity
Primary Language
Secondary Language
Speak English at Home?

YesNo
Receive Ongoing Medical Services?

YesNo
Indian Health Services

YesNo
Migrant Community Health Center

YesNo
Date of last physical
Ongoing Dental Services?

YesNo
Date of last Dental Exam
List anyone NOT allowed to pick up your child
Parental Status

1 parent2 parentsfoster careother legal guardian
Has this child attended a state funded pre-k (ABC) program before?

YesNo
If so, where?
Will this child be concurrently enrolled in an ABC center and HIPPY or PAT program?

YesNo
List any allergies:
Does the child have any special dietary needs? Receiving any special education services?
Medical Insurance Provider
School District the child lives in
Please list individuals approved to pick up your child.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Name

First NameLast Name
Phone Number

Area CodePhone Number
Name

First NameLast Name
Phone Number

Area CodePhone Number
Home Internet Information
Internet Type*

Cellular NetworkCommunity Provided Wi-FiDial-upHot SpotNoneOtherResidential BroadbandSatelliteUnknown
Device Access Source*

District ProvidedOtherPersonal
Learning Device*

ChromebookDesktop ComputerLaptop ComputerNoneOtherSmartphoneTablet
Internet Access Barrier*

Not AffordableNot AvailableOtherN/A
Internet Performance*

No (unable to access internet)Sometimes (regularly experience internet interruptions)Yes (few or no internet interruptions)
Proof of income will need to be provided to Tiffany Bancroft at the Gifford Campus duirng the week of March 30th-April 2nd. At this time you will also fill out and sign the emergency consent form.
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

Glen Rose Pre-Kindergarten Registration

Primary Guardian Information

Secondary Caregiver Information

Household Information

Child Information

Home Internet Information