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

MonthDayYear
Month - Day - Year
Child's Gender:

FemaleMale
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
Additional Phone
If you don't have a phone, can you provide another number for us to reach you?
Is the child Hispanic?

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

AsianBlack/African AmericanNative American/Pacific IslanderNative American/Alaska NativeWhite/European AmericanOther
Is English spoken in the home?

We speak fluent EnglishWe speak some EnglishWe speak no English in the home
If your family speaks other languages in the home, please list which languages:
Has your family ever been homeless?

YesNo
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?

YesNo
If so, who attended, and which classroom did they attend?
FAMILY INFORMATION
My child lives with:

Both parentsMotherFatherOther
Marital status of parents:

SingleMarriedSeparatedDivorced
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?

YesNo
Guardian 1 is:

MotherFatherOther
Guardian 1's Date of Birth

MonthDayYear
Date
Please choose which of these apply for Guardian 1:

UnemployedEmployed full-timeEmployed part-timeIn school full-timeIn school part-time
Guardian 1's place of employment (if employed):
Guardian 1's school (if currently enrolled):
Guardian 1's educational level:

Guardian 1 has not completed high schoolGuardian 1 has a high school diplomaGuardian 1 has a GEDGuardian 1 has attended some collegeGuardian 1 has graduated from college
Guardian 2 is:

MotherFatherOther
Guardian 2's Date of Birth

MonthDayYear
Date
Please choose which of these apply for Guardian 2:

UnemployedEmployed full-timeEmployed part-timeIn school full-timeIn school part-time
Guardian 2's place of employment (if employed):
Guardian 2's school (if currently enrolled):
Guardian 2's educational level:

Guardian 2 has not completed high schoolGuardian 2 has a high school diplomaGuardian 2 has a GEDGuardian 2 has attended some collegeGuardian 2 has graduated from college
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:
Does your child receive any kind of specialized support services? Please check all that apply.

Speech therapyPhysical therapyOccupational therapyABA therapyPlay therapyHome visits from an early interventionistEarly Childhood Support Team Clinical SpecialistsOther
Has your child been identified with any of the following? (Please check all that apply.)

AutismDevelopmental DelayHearing ImpairmentOrthopedic ImpairmentSpeech/Language ImpairmentVisually ImpairedOther
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)?

YesNoI'm not sure
If yes, what agency or school system is it through?

Catawba County SchoolsHickory City SchoolsNewton-Conover City SchoolsChildren's Developmental Services AgencyOther
Does your child have any chronic health problems?

YesNo
If yes, please explain:
Does anyone in your immediate family have any chronic health problems?

YesNo
If yes, please explain:
Is your child currently enrolled in a preschool or a child care program?

YesNo
If yes, where does your child attend?
Have you applied for child care subsidy/scholarships through the Department of Social Services?

YesNo
If yes, please select one:

We currently receive child care subsidies.We are currently on the subsidy waiting list.We do not qualify for subisdy.
If you are not currently enrolled , has your child EVER been enrolled in a child care program?

YesNo
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:*

MonthDayYear
Date
Parent/Guardian Signature*

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