2014-15 Kent County Preschool Intake Form Page 2
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1
2Family Information
Complete the following information about your family. This information is REQUIRED and will be critical for following your
child’s application.
Guardians: You must enter at least one guardian.
Mother
First Name: _______________
Middle Initial: ____ Last Name: ________________
_________________________
Daytime Phone
Father
First Name: _______________
Middle Initial: ____ Last Name: ________________
_________________________
Daytime Phone
Guardian (Relationship): ________________________________________________
First Name: _______________
Middle Initial: ____ Last Name: ________________
_________________________
Daytime Phone
Alternate Phone Number: ________________________ (Whose number is this?) _______________________________
Child Lives With (please check all that apply)
Mother
Joint Custody-Physicial
Legal Guardian
Grandparent
Father
Joint Custody-Legal
Both Parents
Foster Care
Sibiling in Head Start
Street Address ________________________________________ Apt / Suite/ PO Box __________________________
City ____________________________ Zip _______________
Resident District ___________________________
Email Address ________________________________________
Check here if you do not have an email address.
Household Members ____________________________________
Annual Household Income ___________________
Enter the total number of people living in your household
Enter your family’s annual income to the nearest whole dollar
Additional Questions
Is your child currently enrolled in a program?
Yes
No If yes, where? _________________________________
Program Preference:
Morning
Afternoon
Full Day
Please select a second preference if your first preference is not available:
Morning
Afternoon
Full Day
Site Preference _______________________________________________
If you prefer to enroll your child in a program outside of your district of residence, we will make every effort to accommodate your request. This
placement cannot be guaranteed.
Siblings: Please indicate if you have siblings at particular site if you would like this information to be considered in
preschool placement decisions:
Sibling: ____________________________________
Site of sibling: _______________________________
Transportation: Is transportation a barrier to getting your child to a program?
Yes
No
Comments: _______________________________________________________________________________________
________________________________________________________________________________________________
Location where this form was completed: ________________________________________________________________
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