School District 622 Pre-Kindergarten Program Application

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*Completion of the application does not guarantee admission into a program or service

School District 622 Pre-Kindergarten Program Application

The North St. Paul-Maplewood-Oakdale School District recognizes that students who receive high-quality early childhood education are more prepared for success in school and life. Three elementary schools offer a pre-kindergarten program for children the year before entering kindergarten.

Completion of this packet does not guarantee admission into the program. You will be contacted before June 1st_{about your status. To be considered for admission, all applicable forms must be completed. The}

original or copy of the child's birth certificate, passport or other government issued document must also be presented to the enrollment center.

Program Name Age or Residency Requirements Hours

Webster Pre-K At least 4 years-old as of 9-1-2014; live in Webster Elementary attendance area

AM Section: 8:40-11:15 PM Section: 12:45-3:10 Oakdale Pre-K At least 4 years-old as of 9-1-2014; live in Oakdale

Elementary attendance area

AM Section: 8:40-11:15 PM Section: 12:45-3:10 Richardson Pre-K At least 4 years-old as of 9-1-2014; live in

Richardson Elementary attendance area

AM Section: 9:15-11:45 PM Section: 1:15-3:45

Please select your preferences below: If only one section works for you, enter it under first preference Site (must live in

attendance area)

1st_{Preference 2}nd_{Preference No}

Preference  Oakdale

 Richardson  Webster

 AM  PM

 AM

 PM 

To assist the enrollment process, please bring the following items to the Enrollment Center:  The original or copy of the child's birth certificate, passport or other government issued

document.

 Proof of Residency-rental agreement, purchase agreement, utility bill, etc.  Up-to-date immunization records, as required by state law.

 Early Childhood Screening records--Minnesota state law requires that all children participate prior to beginning kindergarten. If your child has not been screened, please call 651-748-7289 to schedule an appointment

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EE Rev 1-8-14

Office Use Only

School (if PK): Program (if ECFE, SR, SS): First Day of Enrollment: Home Primary Language:

______ __ MARSS Code

Student ID #:

North St. Paul-Maplewood-Oakdale ISD #622 Student Enrollment (Early Childhood/Preschool)

USE LEGAL NAME AS STATED ON BIRTH CERTIFICATE

Enrolling Grade: Student LAST Name: Student FIRST Name: Student MIDDLE Name (full):

Nickname: (optional) Student Date of Birth: _{Federal Ethnicity:} (please mark one)

Hispanic/Latino

(Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

YES □ NO □

State Race/Ethnicity: (please mark one or more)

□ 1 American Indian or Alaskan Native

□ 2 Asian

□ 3 Black or African American

□ 4Native Hawaiian or Other Pacific Islander

□ 5 White

Student Gender: Male □ Female □

Previously attended #622 Schools? No □ Yes □ ____ ________ Name of School

Address:______________________________________________________ Home Phone: (______)_______________

STREET APT #

_________________________________________________________________________

CITY ZIP CODE COUNTY DATE STUDENT MOVED INTO THIS ADDRESS

Pick-Up/Daycare Address (if other than home) Yes □ No □ (if yes, please complete the Daycare/Alternate Address Form)

Does another family live at this address with you? Yes □ No □ (if yes, provide name ________________________________)

List all preschool and/or early childhood programs your child has attended(MOST RECENT SCHOOLS FIRST): Name of School/Early Childhood Program City and State Grades/Ages Attended Dates Attended

Student Lives With: Mother □ Father□ Both□ Foster Parent□ Alone□ Other□ ___________________________ Are there court orders that apply to custody of the student? No □ Yes □ (provide copy)

Parent/Guardian #1 Parent/Guardian #2 Parent/Guardian #3 (custodial/resides with student) (non-custodial/second mailing) Name (First, MI, Last)

Gender (Male/Female) Date of Birth (M/D/Y) Relationship to Student (mother, stepfather, etc) Street Address, City, Zip Cell Phone #

E-mail Address Work Phone #

List all additional children residing in the home: (Please indicate if any child has an IEP)

First, MI, Last Name School Attending IEP Y/N

Grade Gender Birthdate Relationship to Enrolling Student

Is the student a Ward of the County or State? (legal documentation required) YES □ NO □ Have you moved into this school district for temporary or seasonal

agricultural or fishing work within the past 36 months? YES □ NO □

Does this student receive Special Education Services (an IEP or IFSP)? YES □ NO □

Does this student have a 504 Accommodation Plan? YES□ NO □

______________________________________________________

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EE Student Home Language Form 1.8.14/rs

Home Language Questionnaire and Child Information Survey (Early Childhood/Preschool)

Child’s Name: ____________________________ Date of Birth: __________________________ Country of Birth: USA  Other ___________________

1. Which language did your child learn first?  English  Other _______________

2. Which language is most often spoken in your home?  English  Other _______________ 3. Which language does your child usually speak?  English  Other _______________ 4. Will you need an interpreter for conferences?  Yes  No

Please answer to the best of your ability.

Has your child ever been separated from you for babysitting, childcare, or preschool?  Yes  No List any concerns you may have about leaving your child:

_____________________________________________________________________________________ _____________________________________________________________________________________ Describe any fears your child has:

_____________________________________________________________________________________ _____________________________________________________________________________________ Are there any limits or restrictions on your child’s participation in daily activities?  Yes  No

If yes, please describe:

_____________________________________________________________________________________ _____________________________________________________________________________________ Please describe any special needs your child has or any concerns you have regarding speech/language, behavior, or other:

_____________________________________________________________________________________ _____________________________________________________________________________________

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Office Use Only SSID: __________________

Early Learning Household Questionnaire

General Information: Please help us learn about your child and family. Neither you nor your child will be identified in any published report. If you do not wish to participate in the parent questionnaire, it will not prevent you or your child from participating in any program or service. All data provided are protected by state and federal data privacy

standards.

If you choose to voluntarily answer the questions, your information will be used by School District 622 and the Minnesota Department of Education for program planning and evaluation in line with state and federal data privacy practices. Again, only aggregated information will be published.

1. Please indicate whether you are this child’s

____Mother ____Father ____Grandmother ____ Grandfather ____Foster Mother ____Foster Father ____Guardian ____ Other Relative

2. Your highest level of school completed. Mark only one. ___ Eighth grade

___ 12th grade

___ High School Diploma ___ Some college but no degree

___ Associate’s Degree ___ Bachelor’s Degree ___ Master’s degree ___ Ph. D.

3. Your Date of Birth (Month/Day/Year) ______/_______/___________

4. Your current job status, mark only one.

___ Employed > 25 hours per week, employed more than 25 hours per week ___ Employed < 25 hours per week, employed less than 25 hours per week ___ Unemployed, seeking employment

___ Unemployed, not seeking employment

5. What was your household’s total yearly income, before taxes last year, rounding to the nearest thousand?

$_______________

6. How many people were in your household last year? Circle one.

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Income Verification for Early Childhood/Preschool Services and Programs

If no household member receives benefits, CONTINUE TO BACK PAGE

Please note: This form is used for program admission purposes only. You will have to complete the Free and Reduced-Price School Meal application in the late summer/early fall before the program begins, if you are accepted. You will receive a separate notice about this form and it can be completed online.

Option 1:

 I have another child who attends a District 622 school on the free and reduced meal program in the same household. If you check this option, you do not need to complete the rest of this form. If you have multiple children from the same household, you only need to enter one below.

Enter the legal name of child receiving free or reduced meals: _________________________________________________ Child’s Date of Birth: ___/___/______

Option 2:

Household income verification. Complete the form below and on the back page (items 1-4)

1. List names of all CHILDREN in household including foster children (use additional form for more than six children)

Last Name First Name Date of Birth

Month/Day/Year

Any Regular Income to Child Example: SSI

Foster Child?

Attends 622 School?