2026-2027 Brunswick Preschool Program ~ Peer Application / Student Information

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

Please complete the following form to add your child to our list as a possible peer model during the 2026-2027 school year. Screenings are held at Kidder Elementary School.

What is a Peer Model?

Peer models are typically developing children three to five years old, selected to participate within the preschool program. While benefiting from the preschool experience, these children provide peer interaction and social motivation for the identified preschooler with a disability. Because all children learn not only from adults, but also from watching and interacting with other children, peer models are an integral part of the preschool program. Peer relationships are important for the social, communicative, and cognitive development of every child.

To provide quality services to our preschool children, it is necessary to charge families of our peer role models a tuition fee that will assist in the ongoing cost of the program along with the purchasing of consumable items used in the pre-kindergarten environment. Some of these consumable items may include snacks and cooking experiences, art supplies, paper products and special events.

Please note, this is a selective process. Therefore, your child is not guaranteed placement. Please have a community preschool alternative in place.

Email *

Child's Last Name *

Child's First Name *

Date of Birth *

YYYY

Age *

Gender *

Female

Male

Name of Parent / Guardian *

Home Address *

Phone Number *

Please List Name and Age or Grade of Siblings *

Please list any medical information, including medications, allergies, and medical diagnoses *

Cognitive - please check the skills your child demonstrates consistently *

Identifies primary colors - red, blue, green, yellow, orange

Identifies basic shapes - square, circle, triagle

Counts 1-5

Identify simple body parts

Know the difference between in vs out

Follows directions with prepositions (in, out, on, off, under)

Knows the difference between big vs little or dirty vs clean

Follows two-step command

Required

Communication -please check the skills your child demonstrates consistently *

Follows simple directions with cues

Uses 2-3 phrases frequently (e.g. I see red car)

Answers yes/ no, simple WHAT, WHERE questions

Asks simple questions

Uses multisyllablic words (butterfly, helicopter)

Required

Please rate the percentage that strangers understand your child when they speak.

25-50%

50-75%

75-100%

Are there any sounds your child has trouble producing? If so, please specify
*

Social - please check the skills your child demonstrates consistently *

Takes turns and shares most of the time

Demonstrates pretend play skills

Separates from parents in familiar surroundings without crying

Able to ask for help

Enjoys playing with other children

Required

Self -help skills - please check the skills your child demonstrates consistently *

Drinks from a cup

Takes food from serving dish with little spilling

Is toilet trained during the day

Undress self except for difficult pullover garments

Can unbutton and zip own clothing

Expresses likes and dislikes

Required

In the bathroom, my child needs help with *

The things my child does (or does not do) that worry me the most are: *

My child uses (please check each item they use): *

Crayons

Pencils

Scissors

Board Games

Electronic Device - Computer / iPad

Markers

Paint

Simple Games

Imaginary Play

Required

My child has attended preschool or daycare *

Yes

If you answered yes, please list where your child has attended preschool or daycare

Does your child receive private / outside therapy, if yes please indicate the services they receive (Check all that apply) *

Speech and Language

Occupational Therapy (OT)

Physical Therapy (PT)

ABA Therapy

Counseling

Other. (please share at screening check-in)

No, my child does not receive private/ outside therapy

Required

When my child disobeys me, I *

Does your child nap during the day? *

Naps in the AM. (ex. 10-12)

Naps in the PM (ex. 1-3)

Language(s) spoken in the home are *

Primary language used by the child is *

Additional information you would like to share with us about your child or questions you may have: *

Screening Date Preference *

January 30, 2026

February 20, 2026

May 1, 2026

Required

To help the district improve communication, please let us know how you heard about this event. *

Social media

District newsletter emailed on Sunday

Superintendent Update emailed out weekly

District website

Other

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Brunswick City School District.

Does this form look suspicious? Report

Forms