Coversheet for Application
Pre-School Location
*
Please Select
Hampton
Harmony Grove
Parkers Chapel
Retta Brown
SAU Tech
Which Classroom?
Student Name
*
First Name
Last Name
How did you find out about our program?
*
Please Select
CommunitY
Former Parent
Friend/Family
Posters
School District
Language spoken by child
*
Language Skills
*
Please Select
Very Well
Well
Not Well
Not At All
Caregiver Insurance
*
Have Insurance?
What insurance do they have?
Primary
Yes
No
Secondary
Yes
No
Caregiver Income
*
Have Income?
Amount
Frequency Recieved
Primary
Yes
No
Secondary
Yes
No
Program Model
*
Please Select
ABC
ABCSS
Paid
If ABC how does the child qualify?
Please Select
Income
Parents without high school diploma/GED
Low birth weight
Parent under 18 at child's birth
Immediate family member history of substance abuse
developmental delay
eligible for services under IDEA
Income for Title I programs
Limited English proficiency
Parent has a history/victim of abuse or neglect
Foster Child
Start Date
*
-
Month
-
Day
Year
Date
Submit
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