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Norwalk Public School 2019-2020 School Readiness Wait List Application
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* Indicates required question
Email
*
Your email
School Location Choice Option 1
*
Choose
ELLI Fox Run
ELLI Jefferson
ELLI Naramake
NECC
ELLI Kendall
Do you currently have a sibling attending this school?
*
Choose
Yes
No
School Location Choice Option 2
*
Choose
ELLI Fox Run
ELLI Jefferson
ELLI Naramake
NECC
ELLI Kendall
Do you currently have a sibling attending this school?
*
Choose
Yes
No
Student First Name
*
Your answer
Student Last Name
*
Your answer
Gender
*
Male
Female
Required
Date of Birth
*
MM
/
DD
/
YYYY
Primary Guardian First Name
*
Your answer
Primary Guardian Last Name
*
Your answer
Norwalk Street Address
*
Your answer
Unit or Apartment Number
Your answer
Zip code
*
Your answer
Contact Phone Number
*
Your answer
Other Contact Phone Number
Your answer
Household Size
Total Number of Adults & Children living at Address Entered Above
*
1-3
4
5
6
7
8
9
10
11
12
Over 12
Row 1
1-3
4
5
6
7
8
9
10
11
12
Over 12
Row 1
Insurance & Health Information
*
My Child is Covered by Private Health Insurance
My Child is Covered under the HUSKY plan
My Child is Not Covered by Any Plan
Required
Estimated Family Annual Income
Proof of Income Required
*
Your answer
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