SECTION1

Bastrop Independent SchoolDistrict

Texas Education Code § 29.153 Free Prekindergarten Application2016-2017

Student’sName:LastFirstMiddle / Child’s Date ofBirth / Child’s Social SecurityNumber
Current Street Address (NO P.O.Boxes) / Current Mailing Address (such as P.O.Box)
CityStateZip / HomePhone:
Full Name ofParent(s)/Guardian(s): / DayPhone:
Total Number inHousehold / Names of each member inHousehold

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Does this child speak and comprehend English? (circle one) Yes / No
If no, what language is spoken primarily by the child: ______ / Is this a Foster Child? (circle one) Yes / No
If yes, you will need to provide a copy of the Letter from DFPS and the 2085.

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Is this a child of an active duty member of the armed forces of the United States? (circle one)Yes / No
If yes, please show military ID
Is this a child of a member of the armed forces who was injured or killed while serving on active duty? (circle one)Yes / No / Are you receiving FOOD STAMPS or TANF benefits for yourchild? (circle one) Yes / No
If yes, provide:
FOOD STAMPcase# ______
TANF case# ______

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Circle the line in the chart below to indicate your current household status:
July 1, 2015 – June 30, 2016 Income Chart to Determine Educationally Disadvantage for Pre – KEligibilityTexas Education Code §5.001,(4)
Total NumberAnnualMonthlyWeekly
Inhousehold
121,7751,815 419
229,4712.456 567
337.1673,098 715
444,8633,739 863
552,5594,3801,011
660,2555,0221,159
767,9515,6631,307
875,6476,3041,455
For eachadditional
family member add: +7,696+642+148
This information only pre-qualifies your student for Prekindergarten. In order to be enrolledin the Bastrop ISD Prekindergarten program due to being economically disadvantaged, youMUST submit the Free & Reduced Lunch Application (available online and on campus)after July 1stand required documentation forformal approval. You will be notified if your student qualifies for Prekindergarten prior to the firstday of school.
TO BE COMPLETED BY SCHOOLPERSONNEL

ProgramQualification Checklist:

(Mark the section student qualifies under & initial & date next to each piece of documentation for verification)

_____Limited English Proficient (allrequired)

  • Home LanguageSurvey ______
  • TestingDocuments ______
  • LPACDate:

_____IncomeEligibility

  • Free and Reduced Lunch Application ApprovalDate:
_____Homeless
  • SRQDate: ______

_____FosterCare

  • Copy of Letter fromDFPS ______
  • Copy of 2085 ______

_____Military (selectone)

  • Department of Defense PhotoID (DO NOT MAKECOPY)
DateReviewed: ViewerSignature:
  • Statement ofService ______
  • Death certificate, PurpleHeart orders orcitation ______
  • Missing inAction ______
  • Line of dutydetermination showing wounded or injured NOTin combat ______
PEIMS CODING(DONE BY CAMPUS REGISTRAR):
Half DayQualify ADA:2
PK Program Code:01
Primary Funding Code:N/A
Secondary Funding:N/A
All Day Paid or ½Day Paid ADA:5
PK Program Code:05
Primary Funding Code:1
Secondary Funding:N/A

APPROVEDDENIED

Signature of Principal orDesigneeDate