Pre-Kindergarten Program Application

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***Note: Students must be four years of age on or before August 31, 2021. ***

This form is only for Derby School District Families who are interested in the Pre-K program for the 2021-2022 school year. If your address zip code is not on the following list, you do not qualify for the program 67037, 67060, 67210, 67216.

We will review the information provided and then we will email you regarding the program.

Email *

Parent or guardian's full name *

Parent/ guardian's phone number *

Address *

Child's Legal First Name *

Child's Legal Middle Name *

Child's Legal Last Name *

Child's Data of Birth *

YYYY

Is the child a Foster student? *

Yes

Does the child have an IEP? *

Yes

Does the child have any other special services? *

Yes

Qualifies for free lunch program on September 20, 2020. *

Yes

Single parent families. At the time of enrollment, the custodial parent is unmarried. *

Yes

Department for Children and Families (DCF) referral. The reason for referral must describe the need for the child to attend the State Pre-Kindergarten Program (4 year AR) program and be documented and signed by the DCF agent. *

Yes

Teen parents (age 13-19). At least one parent was a teen when the child was born. *

Yes

At the time of enrollment, either parent lacks a high school diploma or a GED. *

Yes

The child qualifies for migrant status. There must be a copy of the Certificate of Eligibility on file. *

Yes

English Learner. English Learner status must be documented. NOTE: ESOL services must be provided by qualified teachers. *

Yes

Lower than expected Developmental Progress in at least one of the following areas: Cognitive Developmental; physical * Based on results of an appropriate and valid assessment (screening, authentic assessment, or standardized instrument), which has been administered and interpreted by a trained professional, the 4 development; communication/literacy; social-emotional/behavior; adaptive behavior/self-help skills developmental progress of the child has been determined to be lower than typically expected for his/her chronological age, yet above eligibility requirements for special education services (based the special education eligibility requirement in the Kansas Special Education Process Handbook). *

Yes

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