EMSD #37 PreK Program-Preschool Screening Request 20-21

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

If you are interested in having your child screened for our early childhood program, please fill out the following forms, and an EMSD #37 staff member will contact you.

Today's Date *

YYYY

Child's Name *

Birthdate *

YYYY

Gender *

Ethnicity *

Native American/Alaska Native

African American

Asian

Hispanic/Latino

Caucasian/White

Other:

Languages spoken in your home (check all that apply) *

English

Spanish

French

Arabic

Chin

Other:

Required

If you speak a language other than English, will you or your child need a translator? *

If yes, please list language: *

Child's home address *

Number of times child has moved since birth: *

More than 3

Never moved

Required

Child lives with: *

Both natural parents

One parent

Joint custody

Grandparent

Foster parent

Other:

Parent/Guardian 1 Name *

Parent/Guardian 1 Phone *

Parent/Guardian 2 Name *

Parent/Guardian 2 Phone *

Prior/other enrollment *

Previously enrolled in another preschool/PFA program

Previously enrolled in other program (daycare)

Currently enrolled in another program (other half of the day)

None

What services, if any, is the child currently receiving? (i.e. outpatient therapy, Early Intervention Services) *

No services at this time

Early Intervention Services in my home

Speech/language (outpatient)

Occupational therapy (outpatient)

Required

If we are unable to host in-person screenings, how would you prefer to complete a remote preschool screening? *

Phone interview

Complete online forms

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of East Moline School District 37.

Does this form look suspicious? Report

Forms