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D34 About My Child
Please complete the following form. Upon completion, you will be contacted to schedule a screening to determine if your child qualifies for our Preschool For All Program.
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* Indicates required question
Email
*
Your email
Name of person completing form
*
Your answer
Date
*
MM
/
DD
/
YYYY
Relationship to child
*
Your answer
Child's first name
*
Your answer
Child's Middle Name
*
Your answer
Child's Last Name
*
Your answer
Child's Gender
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Female
Male
Child's date of Birth
*
MM
/
DD
/
YYYY
Is the child Hispanic or Latino?
*
Yes
No
What is the child's race?
*
American Indian or Alaskan Native
Asian or Pacific Islander
Black, Non Hispanic
Hispanic
Mulit- Racial
White, Non Hispanic
Other:
Required
How did you hear about the program?
*
Your answer
Mother's name (or Guardian)
*
Your answer
Mother's (or Guardian) Date of birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Home Phone
*
Your answer
Cell Phone
Your answer
Email
*
Your answer
Marital Status
*
yes
No
Other:
Are you employed?
*
Choose
Yes
No
Place of Employment
Your answer
Address
Your answer
Phone Number
Your answer
Father's Name (or Guardian)
*
Your answer
Father's (or Guardian) date of birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Home Phone
*
Your answer
Cell Phone
Your answer
Email
*
Your answer
Marital status
*
Single
Married
Divorced
Are you employed?
*
Choose
Yes
No
Place of employment
Your answer
Address
Your answer
Phone number
Your answer
Highest grade mother/guardian completed in school
*
Your answer
Highest grade father/guardian completed in school
*
Your answer
Age of mother/guardian at birth of first child
*
Your answer
Age of father/guardian at birth of first child
*
Your answer
Number of people living in the household
*
Your answer
Do you have other children in the district that qualify for free and/or reduced lunch?
*
Choose
Yes
No
Does your family qualify for child care subsidy?
*
Choose
Yes
No
Do you have medical insurance?
*
Choose
Yes
No
My family is enrolled in Medicaid
*
Choose
Yes
No
If yes, specify if child, parent or both are enrolled in medicaid
Your answer
Who does the child live with?
*
Your answer
Does the child have any siblings?
*
Choose
Yes
No
If yes, please list all siblings names and dates of birth
Your answer
Use a few words/phrases to describe your child
*
Your answer
What are some of your child's strengths?
Your answer
Does your child become easily frustrated?
Choose
Yes
No
If yes, what frustrates or upsets your child?
Your answer
What helps keep your child calm?
Your answer
What helps with transitions (ending a favorite activity to begin another activity) or changes in routine?
Your answer
What are some of your child's favorite toys, things to do, or talk about?
Your answer
What language did the child learn when she or he first began to talk?
Your answer
What language does the family speak at home most of the time?
Your answer
What language does the parent(s) speak to the child most of the time?
Your answer
What language does the child speak to his/her parent(s) most of the time?
Your answer
What language does the child hear and understand in the home?
Your answer
What language does the child speak to his/her brothers/sisters most of the time?
Your answer
What language does the child speak to his/her friends most of the time?
Your answer
Can an adult family member or extended family member speak English?
Choose
Yes
No
Can an adult family member or extended family member read English?
Yes
No
Clear selection
Electronic Signature (name of parent/guardian)
*
Your answer
Agreement
*
Agree
Disagree
Required
A copy of your responses will be emailed to the address you provided.
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