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Thank you for your interest in the Mesa K-Ready program for the 2021-22 school year. Please complete and submit this form for each child.
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Child's first and last name
*
Your answer
Child's date of birth
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MM
/
DD
/
YYYY
Child's gender
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Female
Male
Child's ethnicity
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Choose
White Non-Hispanic
White Hispanic
Black/African American Non-Hispanic
Black/African American Hispanic
Asian Non-Hispanic
Asian Hispanic
American Indian/Alaskan Native Non-Hispanic
American Indian/Alaskan Native Hispanic
Native Hawaiian/Other Pacific Islander Non-Hispanic
Native Hawaiian/Other Pacific Islander Hispanic
American Indian/Alaskan Native & White Non-Hispanic
American Indian/Alaskan Native & White Hispanic
Asian & White Non-Hispanic
Asian & White Hispanic
Black/African American & White Non-Hispanic
Black/African American & White Hispanic
American Indian/Alaskan Native & Black Non-Hispanic
American Indian/Alaskan Native & Black Hispanic
Other Multi-Racial Non-Hispanic
Other Multi-Racial Hispanic
Parent/guardian name
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Your answer
Parent/guardian date of birth (birthdate is ONLY used for data purposes)
*
MM
/
DD
/
YYYY
Street address
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Your answer
City
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Your answer
State
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Your answer
Zip
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Your answer
Cell phone (000) 000-0000
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Your answer
Email
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Your answer
Please re-enter your email address
*
Your answer
Relationship to child
*
Choose
Parent
Grandparent
Guardian
Other
How many years have you lived in Mesa?
*
Choose
Less than 1 year
1 to 5 years
More than 5 years
How long have you lived in your current residence?
*
Choose
1 to 3 months
4 months to 1 year
More than 1 year
Approximate annual family combined income level (include everyone working in the home)
*
Choose
$0 to $24,240 per year
$24,241 to $32,920 per year
$32,921 to $42,560 per year
$42,561 to $50,200 per year
$50,201 to $58,840 per year
$58,841 to $67,480 per year
$67,481 to $76,120 per year
$76,121 to $84,760 per year
$84,761 to $93,400 per year
$93,401 to $102,040 per year
Over $102,041 per year
How many people live in your home?
*
Choose
2
3
4
5
6
7
8
More than 8
Do you have transportation to attend our Mesa K-Ready classes during daytime hours?
*
Choose
Yes
No
Sometimes
What is your location preference?
*
Choose
East Mesa - SHARP School satellite campus, 7302 E Adobe St., Mesa, 85207
West Mesa - Mesa Education Center, 855 W. 8th Ave., Mesa, 85210
What is your preferred day of the week to attend class?
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Choose
Monday
Tuesday
Wednesday
Thursday
What is your preferred class start time?
*
Choose
Early morning (possible 9 a.m. start)
Late morning (possible 11 a.m. start)
Early afternoon (possible noon start)
Name of Mesa Public school you plan on sending your Mesa K-Ready child to when they start kindergarten
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Your answer
Is your child currently attending any type of preschool (Head Start, daycare, etc.)?
*
Choose
Yes
No
If yes, please list the name of the program and how long your child has attended.
*
Your answer
How independent is your child when using the restroom?
*
Choose
Goes on their own
Goes with assistance
In pull-ups
How did you hear about the Mesa K-Ready program?
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Word of mouth/friends and family
Community and/or faith organization (church, food bank, social service)
Education provider (MPS, childcare facility, Head Start)
Other media (TV, radio, print)
Museum or library flyer
Other
Primary language spoken at home (English, Spanish, etc.)
*
Your answer
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