Kinderprep Preschool

Bloomington and Richfield Public Schools 2014-2015 School Year

**Please read before filling out the application form**

Kinderprep is a free half day preschool program that meets 4 or 5 half days a week. Classrooms are located in Bloomington and Richfield. Transportation is provided for most students within the regular busing routes.

To Qualify for Kinderprep:

·  Child must live in the Bloomington or Richfield school district

·  Child must be 4 years old on or before September 1, 2014.

·  Child must be an English Language Learner and/or meet income qualifications.

·  Child must be completely toilet trained (no pull-ups or training pants).

·  Child must remain in the program for the entire school year.

Return completed applications to – Kinderprep

Pond Early Childhood Family Center

9600 3rd Ave. South

Bloomington, MN 55420

If you have questions, please call 952-681-6212 or 952-681-6219(Spanish)

Kinderprep Preschool Application

2014-2015 School Year

The following must be included with the application:

Copy of child’s birth certificate

Copy of proof of income for each parent/guardian (2013 tax return)

Verification of your child’s Early Childhood Screening

Immunization records

Today’s Date: ______Location & Date of Screening:

Child Information

Child’s Name: ______/ ______/ ______

Last First Middle

Name child prefers to be called: ______

Date of Birth: ______Male ______Female

English language level of child: ____ none ____low ____medium ____high

Home address: ______City: ______

Zip Code: ______Name of Apartment Building: ______

Address for bus pick up and drop off:

Has your child received Special Education services or therapy (including speech, physical or other therapy)?

Please explain: ______

Do you have any concerns regarding your child? ______

Is your child fully toilet-trained and does not use pull-ups or training pants? ____ yes ____ no

Foods your child cannot eat: ______Reason: ______

Allergies: ______

Medical concerns or conditions: ______

Has your child ever been in day care or preschool?

____Day Care Center: Where? ______For how long? ______

____Preschool: Where? ______For how long? ______

Where will your child attend Kindergarten? (school name)

Family Information

Parent/Guardian one - Name: ______/ ______Relationship to child ______

Last First

Address: ______

Email address: ______

Phone: (home) (work) (cell)

Last completed grade of school of parent/guardian one: ______

English language level of parent/guardian one: ___ none ___ low ___ medium ___ high

Parent/Guardian two - Name: ______/ ______Relationship to child ______

Last First

Address: ______

Email address: ______

Phone: (home) ______(work) ______(cell) ______

Last completed grade of school of parent/guardian two: ______

English language level of parent/guardian two: ____none ____low ____medium ____high

Languages spoken in the home: ______

Ethnicity of child: ______Parents’ country of origin: ______

Length of time family has lived in the United States: ______

Total household family monthly income: $______

Total number of family members supported by this income: ______

List all family members in the household:

Name Relationship to child Age Date of Birth