NMUSD -ECE State Preschool
Eligibility Questionnaire/Cuestionario de elegibilidad
Email address *
Student Full Name/Nombre Completo del Estudiante *
Student Date of Birth/Fecha de Nacimiento *
MM
/
DD
/
YYYY
My Child is/Mi Hijo/a es: *
Gender/Genero *
Address/Dirección *
Program Interest/Programa Interesado *
Required
Number of siblings under 18 years of age living at home/Numbero de hermanos/as menores de 18 años que viven en casa *
N/A if not applicable / N/A si no corresponde
Does your child have an IEP (Individual Education Plan)?/¿Tiene su hijo/a un IEP? (Plan de Educación) *
Father/Legal Guarding Information/Informacion del Padre o Tutor Legal
Questions 1-9
1. Father or Legal Guardian Full Name/Nombre del Padre o Tuto Legal *
N/A if not applicable / N/A si no corresponde
2. Contact Number/Numero de Telefono *
N/A if not applicable / N/A si no corresponde
3. Resides with student/Vive con el estudiante *
N/A if not applicable / N/A si no corresponde
4. Currently (select all that apply)/Actualmente (seleccione todos los que correspondan) *
N/A if not applicable / N/A si no corresponde
Required
5. Occupation/Ocupación *
N/A if not applicable / N/A si no corresponde
6. Monthly Gross Income/Salario Bruto Mensual *
Please include income from employment, cash aid, child support, unemployment, and other. Or N/A if not applicable/Incluya ingresos por empleo, asistencia monetaria, manutención infantil, desempleo y otros. O N/A si no corresponde
7. Type of Income/Tipo de Ingreso *
N/A if not applicable / N/A si no corresponde
Required
8. Pay Schedule/Pago Programado *
N/A if not applicable / N/A si no corresponde
Required
9. Do you receive? (check all that apply)/¿Recibes? (marque todo lo que corresponda) * *
N/A if not applicable / N/A si no corresponde
Required
Mother/Legal Guardian Information/Informacion de la Madre o Tutor Legal
Questions 10-18
10. Mother/Legal Guardian Full Name/Nombre de la Madre o Tuto Legal *
N/A if not applicable / N/A si no corresponde
11. Contact Number/Numero de Telefono *
N/A if not applicable / N/A si no corresponde
12. Resides with student/Vive con el estudiante *
N/A if not applicable / N/A si no corresponde
13. Currently (select all that apply)/Actualmente (seleccione todos los que correspondan) *
N/A if not applicable / N/A si no corresponde
Required
14. Occupation/Ocupación *
N/A if not applicable / N/A si no corresponde
15. Monthly Gross Income/Salario Bruto Mensual *
Please include income from employment, cash aid, child support, unemployment, and other. Or N/A if not applicable/Incluya ingresos por empleo, asistencia monetaria, manutención infantil, desempleo y otros. O N/A si no corresponde
16. Type of Income/Tipo de Ingreso *
N/A if not applicable / N/A si no corresponde
Required
17. Pay Schedule/Pago Programado *
N/A if not applicable / N/A si no corresponde
Required
18. Do you receive? (check all that apply)/¿Recibes? (marque todo lo que corresponda) *
N/A if not applicable / N/A si no corresponde
Required
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Newport-Mesa USD. Report Abuse