Cedar Rapids Early Learning Preschool Registration Information 2017-18

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* 1. Please provide

Child’s Legal First Name:

Child’s Legal Last Name:

Child’s birth date (mm/dd/yy):

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* 2. PLEASE INDICATE YOUR 1ST AND 2ND PREFERENCE OF LOCATION AND REASON.

	1st Choice	2nd Choice
Arthur (NE)	Arthur (NE) 1st Choice	Arthur (NE) 2nd Choice
Cleveland (NW)	Cleveland (NW) 1st Choice	Cleveland (NW) 2nd Choice
Coolidge (SW)	Coolidge (SW) 1st Choice	Coolidge (SW) 2nd Choice
Grant Wood (SE)	Grant Wood (SE) 1st Choice	Grant Wood (SE) 2nd Choice
Harrison (NW)	Harrison (NW) 1st Choice	Harrison (NW) 2nd Choice
Hoover (NW)	Hoover (NW) 1st Choice	Hoover (NW) 2nd Choice
Jackson (NW)	Jackson (NW) 1st Choice	Jackson (NW) 2nd Choice
Kenwood (NE)	Kenwood (NE) 1st Choice	Kenwood (NE) 2nd Choice
Nixon (Hiawatha)	Nixon (Hiawatha) 1st Choice	Nixon (Hiawatha) 2nd Choice
Taylor (SW)	Taylor (SW) 1st Choice	Taylor (SW) 2nd Choice
Viola Gibson (NE)	Viola Gibson (NE) 1st Choice	Viola Gibson (NE) 2nd Choice
Wright (NE)	Wright (NE) 1st Choice	Wright (NE) 2nd Choice

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* 3. REASON:

Daycare

Transportation

Neighborhood school

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* 4. PLEASE INDICATE SESSION PREFERENCE. ALL SESSIONS MEET MONDAY, TUESDAY, WEDNESDAY AND THURSDAY.

A.M. 8:50 – 11:50

P.M. 12:50 – 3:50

Either

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* 5. Preschool Family Information (required):

Guardian/Parent (First Name Last Name)

Guardian/Parent Phone Number

Relationship to student (mother, father, other)

Total number of individuals in your household

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* 6. Preschool Family Information (optional):

Guardian/Parent (First Name Last Name)

Guardian/Parent Phone Number

Relationship to student (mother, father, other)

Shared Visions Funding Information – If you think any of the following criteria pertains to your child, please complete.

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* 7. Do you have documentation that your child is functioning below developmental levels in:

	Yes	No
English Proficiency?	English Proficiency? Yes	English Proficiency? No
Physical Development?	Physical Development? Yes	Physical Development? No
Cognitive/Language Development?	Cognitive/Language Development? Yes	Cognitive/Language Development? No
Social/Emotional Development?	Social/Emotional Development? Yes	Social/Emotional Development? No
Was your child born with a low birth weight?	Was your child born with a low birth weight? Yes	Was your child born with a low birth weight? No
Was your child born with a medical disorder?	Was your child born with a medical disorder? Yes	Was your child born with a medical disorder? No

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* 8. INCOME STATUS (check all that apply)

Free/Reduced Lunch Qualified

Title XIX

SNAP (Supplemental Nutrition Assistance Program)

HAWK I Insurance

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* 9. CHILD/FAMILY NEEDS (check all that apply)

English is child’s second language

English is parent’s second language

Hearing Impairments

Emotional needs

Child Abuse

Refugee

Incarcerated Parent

Parent with drug-alcohol use

Vison Impairments

Foster Child

Parent with spousal abuse

Parent with disability

Working with specialty services such as GWAEA, Unity Point, Witwer

Has a current Individual Education Plan (IEP)

Single Parent Family

Teen Parent

DHS Protective Service Referral

Transitional Housing Family

Homeless Family

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* 10. Please review the following requirements and then enter your name in the box below.

Enrollment for your child will only be considered when all forms listed below are completed and on file in the Early Learning office. This includes:
• Child’s birth certificate
• Family income verification (if the family feels they would be eligible)
• District Enrollment Form
• District Home Language Survey
• Online Preschool Registration Form

By typing in your name below you are acknowledging that you understand the requirements for full enrollment.

Thank You for completing the preschool registration form.

CLICK THE DONE BUTTON NOW.