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REQUEST A PRESCHOOL SCREENING/
SOLICITE UNA PRUEBA DE PREESCOLAR
REQUEST A SCREENING APPOINTMENT FOR DISTRICT 87 PRESCHOOL
PLEASE TYPE IN ALL CAPS
SOLICITE UNA CITA DE EVALUACIÓN PARA EL PREESCOLAR DEL DISTRITO 87 POR FAVOR ESCRIBA TODO EN MAYÚSCULAS
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EMAIL
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Your answer
CHILD DATE OF BIRTH
FECHA DE NACIMIENTO DEL NIÑO
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MM
/
DD
/
YYYY
DOES THE CHILD RECEIVE SPECIAL SERVICES FROM EARLY INTERVENTION (0-3) OR EARLY CHILDHOOD (3-5)? OR HAVE AN IEP? (INCLUDES SPEECH IEPS)
¿EL NIÑO RECIBE SERVICIOS ESPECIALES DE INTERVENCIÓN TEMPRANA (0-3) O NIÑEZ TEMPRANA (3-5)? O TIENE UN IEP? (INCLUYE DISCURSO IEPS)
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YES
No
NOT SURE
CHILD'S LEGAL LAST NAME?
PLEASE USE THE CHILD'S NAME AS WRITTEN ON THE BIRTH CERTIFICATE
¿APELLIDO LEGAL DEL NIÑO? POR FAVOR UTILICE EL NOMBRE DEL NIÑO COMO ESTÁ ESCRITO EN EL CERTIFICADO DE NACIMIENTO
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Your answer
CHILD'S LEGAL FIRST NAME?
PLEASE USE THE CHILD'S NAME AS WRITTEN ON THE BIRTH CERTIFICATE
¿EL PRIMER NOMBRE LEGAL DEL NIÑO? POR FAVOR UTILICE EL NOMBRE DEL NIÑO COMO ESTÁ ESCRITO EN EL CERTIFICADO DE NACIMIENTO
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Your answer
PARENT LAST NAME
APELLIDO DEL PADRE
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Your answer
PARENT FIRST NAME
NOMBRE DEL PADRE
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Your answer
PHONE NUMBER WHERE YOU CAN BE REACHED.
NÚMERO DE TELÉFONO DONDE PUEDE SER LOCALIZADO.
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Your answer
STREET ADDRESS
DIRECCIÓN
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Your answer
CITY
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BELLWOOD
BERKELEY
HILLSIDE
MELROSE PARK
NORTHLAKE
STONE PARK
Other:
WHEN A REPRESENTATIVE FROM THE PRESCHOOL PROGRAM CALLS YOU BACK, WHAT IS THE PREFFERED LANGUAGE?
CUANDO UN REPRESENTANTE DEL PROGRAMA PREESCOLAR LE DEVUELVE LA LLAMADA, ¿CUÁL ES EL IDIOMA PREFERIDO?
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ENGLISH
SPANISH
Other:
WHAT IS YOUR CURRENT HOUSING?
OWN MY HOME
HAVE A CURRENT SIGNED LEASE
LIVES WITH A THIRD PARTY (2B)
OTHER
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PLEASE LIST ANY SIBLINGS THAT ARE CURRENTLY IN DISTRICT 87.
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Your answer
HOME SCHOOL (IF KNOWN)
ESCUELA EN EL HOGAR (SI SE CONOCE)
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WHITTIER PRIMARY
JEFFERSON PRMARY
WHEN IS THE BEST TIME TO BE REACHED?
¿CUÁNDO ES EL MEJOR MOMENTO PARA SER ALCANZADO?
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MORNING
AFTERNOON
EVENING
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