2019-2020 Preschool Financial Application
IMPORTANT: This form should only be filled out by families who believe they will qualify for low income eligibility.
Please fill out the following form to the best of your knowledge. You will be asked to verify that all information is correct to your knowledge. All income is reported as GROSS income which is the total amount BEFORE taxes and deductions.

For families of 4-year-olds in the SVPP program: You may fill out the financial information if you wish to be considered for priority placement. There may also be some additional resources/assistance available to you.

If you are filling out this application for a foster child you only need to fill out the student information—no financial information is needed. You will need to provide a copy of the placement information.

If you have questions please contact Kristin Rourk at 515-633-5071 or rourkk@wdmcs.org

Student's First Name: *
Your answer
Student's Middle Name:
Your answer
Student's Last Name: *
Your answer
Birth-date: *
MM
/
DD
/
YYYY
Your Email:
Your answer
Is this child a foster child? *
If you answer yes, you do not need to fill out the financial information, just provide a copy of the placement information to the Preschool Administrator.
Parent/Guardian #1 First Name: *
Primary Household (where the student resides)
Your answer
Parent/Guardian #1 Last Name: *
Primary Household (where the student resides)
Your answer
Parent/Guardian #1—Employed outside of the home? *
Parent/Guardian #1—Name of Employer *
Your answer
Parent/Guardian #1—Annual Gross Income
All income is reported as gross income, which is the total amount before taxes and deductions.
Your answer
Parent/Guardian #2 First Name
Primary Household Income (where the student resides)
Your answer
Parent/Guardian #2 Last Name
Primary Household Income (where the student resides)
Your answer
Parent/Guardian #2—Employed outside of the home?
Parent/Guardian #2—Name of Employer
Your answer
Parent/Guardian #2—Annual Gross Income
All income is reported as gross income, which is the total amount before taxes and deductions.
Your answer
Child Support (if received)
Monthly x 12
Your answer
Other Income to Household
Monthly x 12
Your answer
Total Gross Annual Income *
*Gross income refers to the total amount before any taxes or deductions.
Your answer
How many people are in this household? * *
Your answer
Is your family eligible for Free/Reduced Lunch? *
Is your family eligible for West Des Moines Human Services? *
Energy Assistance, etc.
Is your family eligible for Women, Infants, Children (WIC)? *
Is your family eligible for Food Assistance? *
I give the Preschool Program Coordinator permission to obtain information from West Des Moines Community Schools Nutrition Services and/or West Des Moines Human Services for income verification if applicable. *
Checking "Yes" below means that the above financial information is true to the best of your knowledge and that you agree to provide income verification as requested. *
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