Math in the Mail 2016-17 Enrollment Form
Math in the Mail is a FREE program that focuses on developing math skills in three-year-olds, by providing the tools needed for parents, guardians, and other caregivers. By increasing pre-school aged math skills and confidence, Math in the Mail will help children gain the math knowledge that will help them have more positive and meaningful science, technology,
engineering and math (STEM) learning experiences in the future.

Families with children born December 1, 2012 through September 1, 2013 should use this form to enroll in the FREE income-based Math in the Mail program.

Child's Last Name
Your answer
Child's First Name
Your answer
Child's Birthday (child must be 3 years old to enroll)
MM
/
DD
/
YYYY
Parent's Name
Your answer
Parent's Email
Your answer
Parent's Phone Number
Your answer
Street Address
Your answer
City
Your answer
State
Zip Code
Your answer
County
School District
Your answer
Address to mail kits to (if different than above):
Your answer
What is your child's primary language?
Your answer
How did you hear about Math in the Mail?
Your answer
Children entering a Head Start or GSRP four-year-old preschool program will be assessed at the beginning of the school year. This assessment information can be used to gauge the effectiveness of the Math in the Mail program and to help secure further funding for the program. The Family Educational Rights and Privacy Act (FERPA) requires consent from parents/guardians to access each child's assessment information. Information about the Family Educational Rights and Privacy Act (FERPA) can be found at www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html
I am the legal parent/guardian of the child named above. [Please type your first and last name below, to be used as your signature.]
Your answer
My family qualifies for Head Start or GSRP preschool.
If you answered yes above, does the Math in the Mail Coordinator have permission to use your proof of income information on file with Head Start/GSRP to qualify your family for Math in the Mail?
Does your family receive... (please check all that apply)
Required
If your family receives Medicaid, Bridge Card, or WIC, please list your ID number here (this will count as proof of income)
Your answer
What is the annual gross income of your household?
Your answer
How many children are living in your household?
Your answer
How many adults are living in your household?
Your answer
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