Arkansas Better Chance Application
Which KidSPOT Clinic Are You Applying For?
Marion
Jonesboro
Primary Caregiver Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Application Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Social Security Number
US Citizen?
Yes
No
Primary Language
Other Language?
Ethnicity (Hispanic):
Yes
No
Race:
Education Level (Choose one)
High School Diploma
GED
Grade 9, 10, 11, or 12
Some College
College Degree
Currently Enrolled in School?
Yes
No
If yes, where? And # of Semester Hours
Marital Status
Married
Single
Separated
Divorced
Widowed
Other
Disabled?
Yes
No
Employment Status (Choose One)
Full Time
Part Time
Homemaker
Unemployed
Retired or Disabled
Self Employed
Seasonal
Immigrant
Employer Name, Work Phone Number, Number of Hours Worked Per Week, Annual Income
Current Housing
Rent
Own
Homeless
Other
Previous Housing
Rent
Own
Homeless
Other
Has Family Moved in Last 24 Months?
Secondary Caregiver Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Social Security Number
US Citizen?
Yes
No
Primary Language
Primary Language
Ethnicity (Hispanic)
Yes
No
Race:
Education Level (Choose One)
High School Diploma
GED
Grade 9, 10, 11, or 12
Some College
College Degree
Currently Enrolled in School?
Yes
No
If yes, where? And # of Semester Hours
Marital Status
Married
Single
Separated
Divorced
Widowed
Other
Disabled?
Yes
No
Employment Status (Choose One)
Full Time
Part Time
Homemaker
Unemployed
Retired or Disabled
Self Employed
Seasonal
Immigrant
Employer Name, Work Phone Number, Number of Hours Worked Per Week, Annual Income
Household Information
Number in Family (The total number of immediate family members living in house)
Number in Household (The total number of people living in house)
List ALL Family Members Living in House (Name and Relationship to Child)
Child Information
Name
First Name
Last Name
Application Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Social Security Number
US Citizen?
Yes
No
Primary Language
Other Language?
Speak English at Home?
Yes
No
English Skills
Very Well
Well
Not Well
Not at All
Ethnicity (Hispanic)
Yes
No
Race:
List Any Allergies or Special Dietary Needs
Currently Receiving Any Special Education Services?
Yes
No
Eligibility Information
Parent Status (Choose all that apply)
Teen Parent
Disabled Parent
Foster Parent
Homeless
Military Parent
Grandparent Guardian
Applicant Disability (Choose One)
No
Suspected
Certified IEP
Certified IFSP
Diagnosis
Additional Child Eligibility (Choose all that apply)
Special Needs
Developmental Delay
Low Birth Weight
Abuse
Incarcerated Parent
Child Protective Services
Parent with Substance Abuse or Addiction
Parent Arrested of Drug Offense
School District Child Currently Lives In
Has Child Attended a State Funded Pre-K (ABC) Program Before?
Yes
No
If yes, where?
Will Child Also Be Enrolled in a HIPPY Program?
Yes
No
If yes, which HIPPY program?
Emergency Contact and Consent
Name of Emergency Contact if Parent/Guardian Cannot be Reached
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Name:
First Name
Last Name
Physician Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I do hereby give consent to the Director/Caregiver of the Childcare Facility or their duly appointed representative, for child named above to receive such medical or surgical aid as may be deemed necessary by a duly licensed or recognized physician or surgeon in case of emergency when the parent can not be reached. Consent is also given for the Director/Caregiver or their duly appointed representative to transport said child for emergency medical treatment if parents can not be reached.
I declare under the penalty of perjury and the rules and regulations of the ABC Program that the information supplied is true and correct at the time of the application. I understand that the information I supplied may be independently verified by the Arkansas Division of Childcare and Early Childhood Education and that any false statements may result in exclusion from DHS Programs and criminal prosecution.
Submit
Submit
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