Arkansas Better Chance Application

Arkansas Better Chance Application
Which KidSPOT Clinic Are You Applying For?
Primary Caregiver Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Application Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Gender
Social Security Number
US Citizen?
Primary Language
Other Language?
Ethnicity (Hispanic):
Race:
Education Level (Choose one)
Currently Enrolled in School?
If yes, where? And # of Semester Hours
Marital Status

Other
Disabled?
Employment Status (Choose One)
Employer Name, Work Phone Number, Number of Hours Worked Per Week, Annual Income
Current Housing

Other
Previous Housing

Other
Has Family Moved in Last 24 Months?
Secondary Caregiver Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Social Security Number
US Citizen?
Primary Language
Primary Language
Ethnicity (Hispanic)
Race:
Education Level (Choose One)
Currently Enrolled in School?
If yes, where? And # of Semester Hours
Marital Status
Disabled?
Employment Status (Choose One)
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 NameLast Name
Application Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Gender
Social Security Number
US Citizen?
Primary Language
Other Language?
Speak English at Home?
English Skills
Ethnicity (Hispanic)
Race:
List Any Allergies or Special Dietary Needs
Currently Receiving Any Special Education Services?
Eligibility Information
Parent Status (Choose all that apply)
Applicant Disability (Choose One)
Additional Child Eligibility (Choose all that apply)
School District Child Currently Lives In
Has Child Attended a State Funded Pre-K (ABC) Program Before?
If yes, where?
Will Child Also Be Enrolled in a HIPPY Program?
If yes, which HIPPY program?
Emergency Contact and Consent
Name of Emergency Contact if Parent/Guardian Cannot be Reached

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Name:

First NameLast Name
Physician Clinic Address

Street Address

Street Address Line 2

CityState / 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.
Should be Empty:

Arkansas Better Chance Application

Primary Caregiver Information

Secondary Caregiver Information

Household Information

Child Information

Eligibility Information

Emergency Contact and Consent