Sebeka School Readiness/Sebeka ”Little Trojans” Preschool
2015 - 2016 Registration Form
Received: ______
Yes, I am interested in having my child in the Sebeka School Readiness/Preschool Program.
Child’s Name:______
Birth Date: ______Age as of September 1st: ______Male ___Female
Parents/Guardians: ______
Address:______
______
County you live in: ______
Home Telephone Number: ______
Cell Phone Numbers: ______
Work Phone Numbers: ______
I would like my child to be in the: _____Morning (2 half days) Session
_____Afternoon (4 half days) Session
What child care does your child attend? ______
Are you able to transport your child to or from his/her home or daycare to attend preschool?
(The Sebeka School District will provide transportation to school for the 8:00 am preschool class and after the afternoon preschool class at 3:00 pm only, if they are on the regular school bus route. Transportation will not be provided at the mid-day pick-up/drop-off times.) Yes No
How did you hear about this preschool program? Please check all that apply.
___ School Mailing ___ Newspaper
___ Early Childhood Screening ___ Early Childhood Special Education
___ Head Start ___ Child Care Program
___ Adult Basic Education and Adult Literacy Program
___ Other: ______
Form Completed By: ______Date: ______
Please return this form to:
Sebeka School Readiness/Little Trojans Preschool Program
Sebeka Public School - Attn: Heidi Huotari-Coordinator/Teacher
200 1st St NW - PO Box 249
Sebeka, MN 56477
Sebeka School Readiness/Sebeka “Little Trojan’s” Preschool
Income and Risk Factor Eligibility Worksheet
1. Income from last year: ______Line 37 from tax form 1040.
(Please indicate combined income of adults in the household.)
2. Who is the primary caregiver in helping to raise the child? Circle all that apply:
Mother Father Grandparent Foster Parent Legal Guardian
3. How many people live in your household: Adults: _____ Children: _____
4. Has your child been adopted? Yes No Date of adoption: ______
5. Is your family eligible for MFIP and/or for Sebeka School District Free and Reduced Lunch Program? Yes No
6. Does your family participate in any of the following programs? Circle all that apply:
Child Care Assistance Food Shelf WIC
7. Please check all that have occurred within the last year:
___ Moved to a new home. ___ Death of a parent.
___ Birth of a new brother or sister. ___ Parents have divorced.
___ Chronic illness of a family member. ___ Chemical issues.
___ Sibling has qualified for special education. ___ Medical issues for your child.
___ Homelessness. ___ Family member in jail or prison.
___ Other issues: ______
8. Does your child speak English fluently? Yes No
If no, which language does your child speak fluently? ______
9. Has your child’s development been on schedule? Yes No
10. What concerns, if any, do you have with your child’s development? ______
______
11. Does your child seem to be more active than other children his/her age?
Yes No
12. Has your child completed his/her early childhood screening (Completed at Wadena County Public Health.)? Yes No
Date screening was completed: ______
Does he/she need to be rescreened? Yes No
13. My child is currently on an IEP: Yes No
14. Is your child potty trained? Yes No
(Children are not required to be potty trained in order to attend preschool.)
15. Has your child ever attended preschool? Yes No