2022-23 Universal Pre-K Application

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OPEN ONLY TO RESIDENTS WITHIN THE CLARKSTOWN SCHOOL DISTRICT BOUNDARIES

Email *

Child's First Name:

Child's Last Name:

Date of Birth:

YYYY

Gender:

Has your child attended other early childhood/preschool programs?

Yes

Clear selection

Language spoken at home (if other than English):

Ethnicity:

Black

American Indian/Alaskan Native

White

Asian

Native Hawaiian/Pacific Islander

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Is your child Hispanic Latino or Spanish Origin:

Yes

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Has the child had an educational evaluation?

Yes

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Custodial Parent/ Guardian First Name:

Custodial Parent/ Guardian Last Name:

Custodial Parent/ Guardian Home Phone Number:

Custodial Parent/ Guardian Cell Phone Number:

Custodial Parent/ Guardian Email Address:

Custodial Parent/ Guardian Relationship: (examples, Mother, Father, Aunt, Uncle, Grandparent, Foster Parent, Sibling):

Please indicate the best form of communication:

Mail

Cell Phone

Home Phone

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Where is the student currently living?

In a shelter

in a hotel/motel

in a car, park, bus, train or campsite

with another family member or other person because of loss of housing or as a result of economic hardship (sometimes referred to as "doubled-up")

In permanent housing

Other temporary living situation (describe in next question)

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Temporary living situation description (If applicable):

Home Address - Street:

Apt #:

City:

State:

Zip Code:

Does this child have siblings?

Yes

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