NEW | Arkansas Better Chance For School Success

Arkansas Better Chance For School Success
Please select the Preschool of your choice?*
What school year are you applying for?*
How did you find out about our program?*

	List Here
Games
Toys
Food

Household Information
Number of people in the family*
Number of people in the household*
Please list the names of people in the household*

Emergency Contact, Consent, and Permission Information
Emergency Contact

(if parent/guardian cannot be reached)
Name*

First NameLast Name
Relationship to child*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this person authorized to pick up the child from the preschool?*

YesNo
List all other adults who are authorized to pick up the child from the preschool.*
Physician Contact
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent for Emergency Medical Care
I give my consent to the Director of the facility, or the representative, for said child to receive medical or surgical aide as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parents cannot be reached. Consent is also given for the Director or duly appointed representative to transport said child for emergency medical treatment if the parents can not be reached.
Primary Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Please select all that apply.*

I give permission for my child to be photgraphed for preschool use.I give permission to use pictures or videos of my child on Social Media (Preschool Facebook Page)I have received a Kindergarten Readiness Calendar (this is provided below to download)I have received the Preschool Handbook (this is provided below to download)I give permission to apply sunscreen to my child.I give permission for my child to be screened by South Central Service Cooperative and information to be released. The following four areas will be screened: hearing, vision, developmental and speech.I give permission for my child to attend planned field trips that I will be notified about prior to the field trip date.
Signature
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 at the time of application. I understand that the information I supplied may be independently verified by the Arkansas Division of Child Care and Early Childhood Education and that any false statements may result in exclusion from DHS programs and criminal prosecution.
Primary Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Kindergarten Readiness Calendar and Preschool Handbook can be downloaded below by clicking the down arrow.
Kindergarten Readiness Calendar
Preschool Handbook

Enrollment Documents

These are the documents that will be required for enrollment. Uploading these documents will save time and make the acceptance process quicker. If you do not have a scanner then you can take a CLEAR picture of the documents. If needed, we will request a clearer document.
Legal Birth Certificate

Cancelof
Insurance Card

Cancelof
Proof of Income

Cancelof
Health Screening

Cancelof
Immunization Record

Cancelof
Should be Empty:

	Yes	No	If yes, please list the dates of when the child had the disease.
Measles
Mumps
German Measles
Chicken Pox
Whooping Cough

	Yes	No
Contracted Tuberculous
Had Frequent Ear Infections
Had Frequent Throat Infections
Defective Heart

	Yes	No
Diabetes
Seizures
Fainting Spells
Frequent Colds
Sun Sensitivity
Temper Tantrums
Biting
Bed Wetting

	Yes	No
Dressing
Undressing
Toileting
Eating
Washing Hands

Arkansas Better Chance For School Success

Cover Sheet for Application

Child's Personal Data Sheet

Emergency Contact Information

Physician Contact

Consent for Emergency Medical Care

Child Information

Disease History

Child's Developmental Needs

Primary Guardian Information

1st Primary Guardian

2nd Secondary Caregiver Information

Household Information

Emergency Contact, Consent, and Permission Information

Emergency Contact

Physician Contact

Consent for Emergency Medical Care

Signature

Kindergarten Readiness Calendar and Preschool Handbook can be downloaded below by clicking the down arrow.

Enrollment Documents