CONFIDENTIAL MATERIAL
PRE-KINDERGARTEN APPLICATION
2018-2019
Albert Lea School District 241
Child's Name ______
Last First Middle
Date of Birth ______Gender ______
(mm/dd/yyyy)
Home Address ______Home Phone: ______
______Cell Phone: ______
Email: ______
Do you need an interpreter? (circle one) YES NO Language Needed: ______
Person completing this form______Relationship to child (circle one below)
Mom Dad Step-Mom Step-Dad Foster Mom Foster Dad Female Guardian Male Guardian
Grandmother Grandfather Aunt Uncle Other Female Relative Other Male Relative
Family Size: ______
Child lives with: Both parents ____Mother only ____Father only ____
Other (explain): ______
Who has legal custody of the child? ______
Father's name ______Mother's name ______
Please check all programs in which you and/or your child have participated.
□ District 241 Pre-Kindergarten □The Children's Center (Albert Lea)
□ Early Childhood Family Education Parent/Child Classes □Family Day Care Home
□Tiger Cub (ECFE) □ St. Theodore Preschool
□United Preschool (Albert Lea)□Sunday School
□Head Start□ Adult Basic Education Childcare
□Early Childhood Special Education□ Library Story Hour
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- Describe your child's emotional and social behavior, i.e., personality traits and how they play/work with others.
______
- Do you have behavior concerns about your child?
______
- Do you have any concerns about your child's health and development?
______
- Has your child had any hospitalizations, serious illness or accidents?
Describe______
- Is your child toilet trained? (Students must be able to use the toiletindependently, meaning they must not use pull-ups and need to be able to pull pants up and down on their own, as well as clean themselves without adult assistance.)
Day _____ Night _____
- Are there significant stresses or worries in your life as a parent now? What are they?
______
- Is there any previous history of alcoholism or chemical dependency in your family?
______
- Why do you believe your child needs a preschool program and is there any other information we should know in considering this application?
______
- Is your child currently receiving early childhood special education service? _____ Yes _____ No
Type of service ______
- Has your child had an early childhood screening? ______Yes ______No
Date: ______Location: ______
Were there any recommendations, referrals, or re-screens made to you by the screeners concerning your child's learning readiness?
______
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ATTENTION: Early Childhood Screening is required prior to participation in a Pre-Kindergarten Preschool. If your child has not completed this process, please call 379-5176 to schedule your child’s screening appointment.
DATA PRIVACY RIGHTS OF APPLICANTS
Federal and State laws protect your right to privacy. We are asking you for private information about your child and household. You are not legally required to provide this information. The purpose of this information is to determine program eligibility. At no time will information which identifies you or any member of your household be revealed unless you give your written permission. Only program staff whose jobs require access to this information may have access.
Summer Screening Dates
Tuesday, June 19 1:00-4:00 p.m.
Wednesday, June 20 8:00-11:00 a.m.
Thursday, June 21 3:00-6:00 p.m.
Tuesday, July 24 8:00-11:00 a.m.
Wednesday, July 25 1:00-4:00 p.m.
Thursday, July 263:00-6:00 p.m.
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PARTICIPANT QUESTIONNAIRE
How long have you lived at your present address? (check one only):
□a. Less than 1 year□b. 1-3 years□c. 4-5 years□d. More than 5 years
Highest level of both parents' education. Mark M for mom and D for dad:
____ Some high school____ Some college or trade school
____High school diploma____ Bachelor's Degree
____ G.E.D.____ Graduate Degree
What is your child(ren)'s age(s)? (Indicate for ALL your children)
□a. Birth-5 months□c. 13-23 months□e. 3 years□g. 5 years
□b. 6-12 months□d. 2 years□f. 4 years□h. 6-12 years□i. 13+ years
What is your household's total yearly income, before taxes? (check only one):
□a. Under $10,000□c. $20,000 to $29,999□e. $40,000 to $49,999□g. $75,000 to $99,999
□b. $10,000 to $19,999□ d. $30,000 to $39,999□ f. $50,000 to $74,999 □ h. $100,000 or more
Mother's age at birth of first child:
□ Under 20 years old□ b. 20-29 years old□c. 30-39 years old □d.40 years old or older
Your current job status (mark M for mom, D for dad)
□ a. Not seeking employment □ c. Employed less than 25 hours per week
□ b. Unemployed, seeking employment□ d. Employed 25 hours or more per week□ e. Student
Please indicate your Child’s Race/Ethnicity. Circle each YES or NO. More than one may be circled YES.
YES NO Hispanic/Latino
YES NO White
YES NO American Indian/Alaska Native
YES NO Native Hawaiian/Pacific Islander
YES NO Asian
YES NO Black/African American
Language:What language is used most often in the home? ______
What language does your child speak? ______
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Voluntary Pre-Kindergarten (4 Year Olds ONLY)
The following class sections are for children who will be 4 years old by September 1, 2018.
Availability of this program is contingent on state approval of the VPK grant.
Please select the Pre-Kindergarten Preschool sections you prefer. You MUST rank your selected VPK classes in order of preference (1st 2nd choice), as well as a Brookside option.
Please Note: Wraparound Child Care is optional and is only available to children enrolled in District #241 Pre-Kindergarten preschool programs. Meal service fee during class time and Wraparound will be based on Free & Reduced Meal eligibility.
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Voluntary Pre-Kindergarten
Student must be 4 yrs. by September 1, 2018
(VPK applicants must meet admission criteria)
HALVERSON-Morning
______Monday-Friday, 8:00-11:05AM
(172 Scheduled School Days)
*Only Halverson and Sibley residents are eligible to apply
The Children’s Center-Morning
______Monday-Friday, 8:00-11:05AM
(172 Scheduled School Days)
*Only Hawthorne and Lakeview residents are eligible to apply
HALVERSON-Afternoon
______Monday-Friday, 12:00-3:05PM
(172 Scheduled School Days)
*Only Halverson and Sibley residents are eligible to apply
The Children’s Center-Afternoon
______Monday-Friday, 12:00-3:05PM
(172 Scheduled School Days)
* Only Hawthorne and Lakeview residents are eligible to apply
WrapAround Child Care
4 Year OldWrapAround Child Care
Brookside Education Center Fee/Month
______Option 1: 6:15am-7:45am$93/month
______Option 2: 11:15am-2:30pm$201/month
______Option 3: 11:15am-4:00pm$293/month
______Option 4: 11:15am-5:45pm$399/month
______Option 1: 6:15-11:45am$338/month
______Option 2: 7:15-11:45am$278/month
______Option 3: 8:30-11:45am$201/month
______Option 4: 3:15-4:15pm$63/month
______Option 5: 3:15-5:45pm$155/month
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Bus Options
I WILL NOT need busing.
I WILL need busing.
Please indicate the address where your child will be picked up.
______
Please indicate the address where your child will be dropped off.
______
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Brookside Pre-Kindergarten (4-5 Year Olds)
The following class sections are for children who will be at least 4 years old by September 1, 2018.
Please select the Pre-Kindergarten Preschool sections you prefer. You MUST rank in order of preference: 1st or 2nd choice.
Please Note: Wraparound Child Care is optional and is only available to children enrolled in any of the following Pre-Kindergarten preschool programs. Meal service fee during Wraparound will be based on Free & Reduced Meal eligibility.
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Pre-Kindergarten Preschool
4-5 Year Old Preschool Classes
Brookside Education Center
______Monday-Friday, 8:30-11:00AM
(172 Scheduled School Days)
______Monday-Friday, 12:00-2:30PM
(172 Scheduled School Days)
WrapAround Child Care
4-5 Year Old WrapAround Child Care
Brookside Education Center Fee/Month
______Option 1: 6:15-8:30am$140/month
______Option 2: 7:15-8:30am$78/month
______Option 3: 11:00am-2:30pm$218/month
______Option 4: 11:00am-4:00pm$310/month
______Option 5: 11:00am-5:45pm$419/month
______Option 1: 6:15am-12:00pm$358/month
______Option 2: 7:15am-12:00pm$293/month
______Option 3: 8:30am-12:00pm$218/month
______Option 4: 2:30-4:00pm$93/month
______Option 5: 2:30-5:45pm$201/month
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Bus Options
SMART Transit options are yet to be determined. Please indicate here if you would like to be notified when transportation details become available.
Please indicate the address where your child will be picked up.
______
Please indicate the address where your child will be dropped off.
______
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Brookside Pre-Kindergarten (3 Year Olds)
The following class sections are for children who will be at least 3 years old by September 1, 2018.
Please Note: Wraparound Child Care is optional and is only available to children enrolled in any of the following Pre-Kindergarten preschool programs. Meal service fee during Wraparound will be based on Free & Reduced Meal eligibility.
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Pre-Kindergarten Preschool
3 Year Old Preschool Classes
Brookside Education Center
______Monday-Thursday, 8:30-11:00AM
(139 Scheduled School Days)
WrapAround Child Care
3 Year OldWrapAround Child Care
Brookside Education Center Fee/Month
______Option 1: 6:15-8:30am$113/month
______Option 2: 7:15-8:30am$63/month
______Option 3: 11:00am-2:30pm$176/month
______Option 4: 11:00am-4:00pm$250/month
______Option 5: 11:00am-5:45pm$338/month
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Bus Options
SMART Transit options are yet to be determined. Please indicate here if you would like to be notified when transportation details become available.
Please indicate the address where your child will be picked up.
______
Please indicate the address where your child will be dropped off.
______
Income Verification
You have two options for verifying your income. CHOOSE ONE of the two options.
Option 1- Provide proof that your child/children is/are currently participating in one of the following public assistance or publicly funded programs below:
- Minnesota Family Investment Program (MFIP)
- Child Care Assistance Program (CCAP)
- Food Support (SNAP)
- Free and Reduced-Price Lunch Program (CACFP)
- Head Start
- Foster Care
- Food Distribution Program on Indian Reservations
You must provide written documentation type proof of participation (showing participation)
Option 2- List all sources of income in the table below. Each member of your household (including yourself, another parent or legal guardian) must be listed. All sources of income require proof of income (evidence).
Family Member / Source of Income / Amount Received(enter what is verifiable) / How Often
Total:
Provide proof of income for each family member listed in the income table. Proof of income may include:
- A recent tax form
- W-2 form
- Two most recent pay stubs
- Financial aid statements
- Statement from your employer on company letterhead
Pre-Kindergarten Program Fee Chart
Please complete the following form with the requested information along with your signature.
2 / Below $19,999 / 20,000-24,999 / 25,000-29,999 / 30,000-39,999 / 40,000-49,999 / 50,000 & 3 / Below $24,999 / 25,000-29,999 / 30,000-34,999 / 35,000-44,999 / 45,000-54,999 / 55,000 &
4 / Below $29,999 / 30,000-34,999 / 35,000-39,999 / 40,000-49,999 / 50,000-59,999 / 60,000 &
5 / Below $34,999 / 35,000-39,999 / 40,000-44,999 / 45,000 -54,999 / 55,000-64,999 / 65,000 &
6 / Below $39,999 / 40,000-44,999 / 45,000-49,999 / 50,000-59,999 / 60,000-69,999 / 70,000 &
Category / A / B / C / D / E / F
Voluntary Pre-Kindergarten or Scholarship Recipient
4-5 days/week / Free For Qualifying Families / Free For Qualifying Families / Free For Qualifying Families / Free For Qualifying Families / Free For Qualifying Families / Free For Qualifying Families
5 days/week / $60 / $75 / $85 / $110 / $125 / $155
4 days/week / $50 / $60 / $70 / $90 / $100 / $125
Category / A / B / C / D / E / F
To calculate your fee:Fees may be paid on a monthly basis or the full fee.
- Locate your family size(Calculate full annual fee by multiplying the
- Locate your annual income before taxesmonthly fee X 9)
- Move down that column to the corresponding rate
Family Annual Income$ ______Fee Category (Circle one) A B C D E F
(See the totaled amount from the income table on page 8. If
weekly pay was entered, multiply the total by 52. If bi-weekly
pay was entered, multiply the total by 26. Monthly pay
should be multiplied by 12.)My family’s monthly class fee $ ______
Please Note:
If your family is in category A, B, C, or D, you may qualify for a Scholarship. Additional paperwork is required. Contact Kate Richards at 379-4838 for more information.
I certify that this information is true and correct. I understand that school officials may verify the information and that deliberate misrepresentation may subject me to prosecution under applicable laws. I will notify the school immediately if:
(1)Our total household income increases by more than $100/month
Signature of Adult Household Member (required) ______
Print Name ______
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