Preschool Reduced Family Tuition

DC West Community Schools Early Childhood Reduced Tuition Application

For Families living in the DC West School District Only
Childs Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Parent/Guardian Name*
Home Phone:*
Cell Phone:*
Address*
Address/City
Email*
example@example.com
Preschool tuition will be established based on documented family income. Figures are based on annual gross income. Income verification is required at the time of application (e.g. tax return, W-2, pay stubs. If your income falls at or below the following guidelines, you may qualify for reduced tuition.

The reduced tuition guidelines are outlined below.
Family Unit

(People Residing in Household - Adults and Children)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Household Income
Yourself - Income *
Income
Yourself - Payment Frequency*
Yourself -Employer*
Yourself - Secondary Income (if applicable)
Income
Yourself - Secondary Income Payment Frequency (if applicable)
Yourself - Secondary Employer (if applicable)
Spouse - Income
Income
Spouse - Payment Frequency
Spouse - Employer
Spouse - Secondary Income (if applicable)
Income
Spouse - Payment Frequency (if applicable)
Spouse - Employer (if applicable)
Income verification MUST be provided with this application in order to be considered for Reduced Tuition. Please attach verification below.

I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief.I agree that any misleading or falsified information and/or omissions may disqualify me from further consideration for the DC West Early Childhood sliding scale fee/tuition reduction program. | further agree to inform the DC West Community Schools if there is a significant change in my income. I hereby acknowledge that I read the foregoing disclosure and understand it.
File Upload

Cancelof
ParentGuardian Signature*

Clear
Date

MonthDayYear
Date
DC West Early Childhood Center

400 S. Center St.

PO Box 378

Valley NE 68064

For questions, contact Kristi Trost at 402-359-2583
Should be Empty:

Family Unit

Household Income