Glen Rose Pre-Kindergarten Registration

Glen Rose Pre-Kindergarten Registration

2022-2023 School Year
Child's Name

First Name Middle Name Last Name
Primary Guardian Information
Primary Guardian (with most contact with child)

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

Street Address

Street Address Line 2

City State / Province

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

Street Address

Street Address Line 2

City State / Province

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

Rent Own Homeless
Receive WIC

Yes No Previously
Has your family moved in the last 24 months?

Yes No
Food Stamps?

Yes No
Marital Status
Secondary Caregiver Information
or

Single Parent Household
Secondary Caregiver

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

Street Address

Street Address Line 2

City State / Province

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

Street Address

Street Address Line 2

City State / Province

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

Rent Own Homeless
Receive WIC

Yes No Previously
Has your family moved in the last 24 months?

Yes No
Food Stamps?

Yes No
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 Name Middle Name Last Name
Date of Birth

Month Day Year
Date
Social Security #
Gender
Ethnicity
Primary Language
Secondary Language
Speak English at Home?

Yes No
Receive Ongoing Medical Services?

Yes No
Indian Health Services

Yes No
Migrant Community Health Center

Yes No
Date of last physical
Ongoing Dental Services?

Yes No
Date of last Dental Exam
List anyone NOT allowed to pick up your child
Parental Status

1 parent 2 parents foster care other legal guardian
Has this child attended a state funded pre-k (ABC) program before?

Yes No
If so, where?
Will this child be concurrently enrolled in an ABC center and HIPPY or PAT program?

Yes No
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 Name Last Name
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
Home Internet Information
Internet Type *

Cellular Network Community Provided Wi-Fi Dial-up Hot Spot None Other Residential Broadband Satellite Unknown
Device Access Source *

District Provided Other Personal
Learning Device *

Chromebook Desktop Computer Laptop Computer None Other Smartphone Tablet
Internet Access Barrier *

Not Affordable Not Available Other N/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.
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Glen Rose Pre-Kindergarten Registration

Primary Guardian Information

Secondary Caregiver Information

Household Information

Child Information

Home Internet Information