2425 HPSPreschoolApplication-JotForm

2024-2025 Hickory City Schools
Preschool Application

Child's First Name:

Child's Middle Name:

Child's Last Name:

Child prefers to be called:

Child's Birth Date

Month - Day - Year

Child's Gender:

County

Mother/Guardian's Name:

Father/Guardian's Name:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email address

example@example.com

Primary Phone

Format: (000) 000-0000.

Additional Phone

Format: (000) 000-0000.

If you don't have a phone, can you provide another number for us to reach you?

Format: (000) 000-0000.

Is the child Hispanic?

Child's Race/Ethnicity (please check all that apply):

Is English spoken in the home?

If your family speaks other languages in the home, please list which languages:

Has your family ever been homeless?

What elementary school will your child attend?

PRESCHOOL CLASSROOM CHOICES
(We cannot guarantee placement into your first choice location, but we do our best to match up preferences with placements.)

What is your 1st choice for a preschool classroom?

What is your 2nd choice for a preschool classroom?

What is your 3rd choice for a preschool classroom?

Has anyone in your family ever attended a preschool with the Hickory City Schools in the past?

If so, who attended, and which classroom did they attend?

FAMILY INFORMATION

My child lives with:

Other

Marital status of parents:

If you have any formal or informal custody agreements, please let us know:

Are either of the child's parents or guardians an active duty member in the armed forces?

Guardian 1 is:

Other

Guardian 1's Date of Birth

Date

Please choose which of these apply for Guardian 1:

Guardian 1's place of employment (if employed):

Guardian 1's school (if currently enrolled):

Guardian 1's educational level:

Guardian 2 is:

Other

Guardian 2's Date of Birth

Date

Please choose which of these apply for Guardian 2:

Guardian 2's place of employment (if employed):

Guardian 2's school (if currently enrolled):

Guardian 2's educational level:

List all other adults living in the household. (Include name and relationship to the child.)

Example: Jane Doe, grandmother

List all other children living in the household. (Include name, age, grade, and school.)

Example: Jacob Doe, 6, 1st grade, Viewmont

Please provide the name of an emergency contact person, other than the parents/guardians (include name and relationship to the child):

Example, Jane Doe, grandmother

Phone number for emergency contact:

Format: (000) 000-0000.

Does your child receive any kind of specialized support services? Please check all that apply.

Has your child been identified with any of the following? (Please check all that apply.)

If so, what agency or school system are you working with?

When was the disability identified?

Month and Year

Does your child have an Individualized Education Program (IEP) or an Individualized Family Education Plan (IFSP)?

If yes, what agency or school system is it through?

Does your child have any chronic health problems?

If yes, please explain:

Does anyone in your immediate family have any chronic health problems?

If yes, please explain:

Is your child currently enrolled in a preschool or a child care program?

If yes, where does your child attend?

Have you applied for child care subsidy/scholarships through the Department of Social Services?

If yes, please select one:

If you are not currently enrolled , has your child EVER been enrolled in a child care program?

If yes, when and where did your child attend?

Example: ABC Preschool, age 2

Who currently takes care of your child during the day?

Example: ABC Preschool, age 2

PARENT/GUARDIAN SIGNATURE IS REQUIRED

I certify that all of the information on both sides of this application is true to the best of my knowledge. I understand I am responsible for calling Hickory City Schools (828-322-2855, ask for Corie Schreiber or Dr. Sims) with any changes to information on this application (phone number, address, work status, income, etc.). I give my permission for the information on this application and any other documentation that I submit with this application to be released to the classroom staff, the Division of Child Development and Early Education, and others as necessary. I understand that knowingly providing inaccurate information will result in this application being rejected.

Please type your name:

Today's Date:

Date

Parent/Guardian Signature