2021-22 Pre-Kindergarten Enrollment Application
To enroll an eligible child, the child’s parent or guardian shall furnish documentation of eligibility and other required information, including household income and household member information. Children of parents or guardians refusing to furnish required information shall be deemed ineligible for participation. –Arkansas Better Chance Rules and Regulations, 4.05
PRE_KINDERGARTEN STUDENT INFORMATION
What language do you speak?
*
Please Select
I speak English
I Speak Spanish
I speak another language
If other, what language do you speak
Student Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Gender
*
Male
Female
Race
*
Black/African American
White/Caucasian
Hispanic
Native American
Asian
Hawaiian/Pacific Islander
Does child have medical insurance
*
Yes
No
Type of Medical Insurance
AR Kids 1st
AR Kids A/B
Medicaid
Medicare
Other
If other medical insurance, please list
Will child also be enrolled in HIPPY or (Parents as Teachers) PAT?
*
Yes
No
Child's Medical Doctor
Doctor's Location
Children's (ACH)
Other
If Doctor's location is other, please list
Child's Dentist
Dentist's Location
Children's (ACH)
Other
If Dentist's location is other, please list
HOUSEHOLD INFORMATION
Current Address
*
City/Zip Code
*
Phone Number
*
Please enter a valid phone number.
Total number in the Family (Parents/children):
*
Total number who live in the home
*
Do you receive WIC?
*
Yes
No
Previously
Do you receive Food Stamps
*
Yes
No
Current Housing
*
Rent
Own
Homeless
Other
If housing is Other, please list
Has the family moved in the last 24 months?
Yes
No
If yes, previous housing
Rent
Own
Homeless
Other
If previous housing is other, please list
PARENT/GUARDIAN (PRIMARY CAREGIVER) LIVING IN THE HOME
Parent Guardian Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Relationship to Child:
*
Parent
Legal Guardian
Marital Status
*
Married
Single
Divorced
Widowed
Legally Seperated
Employment Status
*
Full Time
Part Time
Unemployed
Retired
Disabled
Education Level
*
High School
GED
College
Bachelors or higher
Race
*
Black/African American
White/Caucasian
Hispanic
Native American
Asian
Hawaiian/Pacific Islander
Name of Medical Insurance Provider
PARENT/GUARDIAN (SECONDARY CAREGIVER) LIVING IN THE HOME
Parent/Guardian Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Relationship to Child
Parent
Legal Guardian
Marital Status
Married
Single
Divorced
Widowed
Legally Seperated
Employment Status
Full Time
Part Time
Unemployed
Retired
Disabled
Education Level
High School
GED
College
Bachelors or higher
Race
Black/African American
White/Caucasian
Hispanic
Native American
Asian
Hawaiian/Pacific Islander
Name of Medical Insurance Provider
Please check checkboxes below to accept the following conditions:
If assigned a Pre-K seat, I acknowledge the need to check in and attend school. If we fail to check in or attend the assigned school within the first five days of school, the assigned seat will be forfeited and assigned to another child.
*
I understand
I understand transfers for older siblings of P3 or P4 students to his/her school WILL NOT BE GRANTED
*
I understand
I declare under the penalty of perjury and the rules and regulations of the Arkansas Better Chance program that the information supplied is true and correct.I understand that the information I supplied may be independently verified by the Arkansas Division of Child Care and Early Childhood Education. Any false statements may result in exclusion from DHS programs including LRSD Prekindergarten program and criminal prosecution.
Signature
*
Date
*
-
Month
-
Day
Year
Date
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