Summer Preschool Application

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* 1. Child's Full Name

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* 2. Child's Date of Birth

Date / Time

Date

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* 3. Desired Location (please rank)

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* 4. Does your child have any special needs or health conditions such as asthma or allergies?

If so, please describe

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* 5. Parent/Guardian Name

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* 6. Parent/Guardian email address

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* 7. Parent/Guardian Best Contact Phone Number

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* 8. The following items assist in determining eligibility. Please check all that apply:

My child has experienced homelessness, has been in foster care, is under child protection or is the child of teenage parents

My child or child's family participates/receives SNAP, cash benefits, Child Care Assistance Program, reduced or free lunch program or receives other public assistance benefits

My child is receiving special education services or is in the process of being evaluated for developmental delays, speech therapy or other special education services

My child has not attended or received a prekindergarten experience

My child has disruptions in their prekindergarten experience due to Covid

My child is a current or former student a Learning Garden Center

None of the above

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* 9. I understand that my child must be 4 years old by September 1, 2020 and that they must attend 100 hours of instruction (attend every day) in order to be eligible for this free preschool opportunity.

Yes

Summer Preschool Application

Question Title

* 1. Child's Full Name

Question Title

* 2. Child's Date of Birth

Question Title

* 3. Desired Location (please rank)

Question Title

* 4. Does your child have any special needs or health conditions such as asthma or allergies?

Question Title

* 5. Parent/Guardian Name

Question Title

* 6. Parent/Guardian email address

Question Title

* 7. Parent/Guardian Best Contact Phone Number

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* 8. The following items assist in determining eligibility. Please check all that apply:

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* 9. I understand that my child must be 4 years old by September 1, 2020 and that they must attend 100 hours of instruction (attend every day) in order to be eligible for this free preschool opportunity.

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* 10. Electronic Signature