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Bristol Public Schools

Pre-K Progam Application

Student's Full Name

First Name

Initial

Last Name

Student's Date of Birth

Month

Day

Year

Parent/ Guardian #1 Name

First Name

Initial

Last Name

Parent/ Guardian #1 Address

Street Address

City

State

Zip

Parent/ Guardian #1 Primary Phone Number

Parent/ Guardian #1 Email Address

Parent/ Guardian #1 Employer

Parent/ Guardian #1 Work Number

Parent/ Guardian #2 Name

First Name

Initial

Last Name

Parent/ Guardian #2 Address

Street Address

City

State

Zip

Parent/ Guardian #2 Primary Phone Number

Parent/ Guardian #2 Email Address

Parent/ Guardian #2 Employer

Parent/ Guardian #2 Work Number

Parents are:

Married

Single

Separated

Divorced

List names of other children in the home. Please include age and grade.

Child's Developmental History. Please check that apply.

Low birth weight (unmder 3 lbs 4 oz

Eating and growth problems

Asthma

Developmental concerns

Premature birth (under 7 1/2 months)

Lead poisoning

Frequent ear infections

Is the child toilet trained? At what age?

Does the child have food allergies? Please list.

Do you have any concerns about your child's:

Listening and understand

Ability to talk clearly

Seeing clearly

Amount of energy

Please explain concerns above

Did your child receive Birth to 3 services?

Does your child have an IEP?

What language is spoken at home?

Do you need a translator?

What language does the child speak at home?

Was your child previously enrolled in Bristol Public Schools, preschool program?

If yes, what School/Teacher?

Please check all the words that make you think of your child:

Have any other of your children been enrolled in Bristol Public Preschools?

If so, which program?

Were you referred by a Bristol Preschool Family?

If so, who referred you?

Are there any smokers in the house?

Highest level of education for the Mother?

Highest level of education for the Father?

What specific family structure would you like to share with us? (Religious, cultural, educational)

Is there a history of learning disabilities?

Did or does your child attend another preschool?

Name and address of preschool previously or currently attending.

*The Bristol School Readiness Program is open to all Bristol residence. Tuition is based on the State of Connecticut Office of Early Childhood sliding scale fee. The fee is determined based on family size and income. Additional reduction may be available to families that meet the hardship guidelines.

The following questions are required as part of the School Readiness Grant program.

Child's Race. Check all that apply:

Asian

Black

Hispanic

White

Other

Does your family receive state assistance?

Does your child have public or private health insurance?

Nutrition Questionaire for Children

How would you describe your child’s appetite? (Check one)

How many days per week does your family usually eat meals together?

How would you describe mealtimes with your child?

How many meals does your child usually eat per day?

Which of these foods did your child eat or drink last week?

Grains

Vegetables

Fruits

Milk and Other Dairy Products

Whole milk

2% milk

1% milk

Skim milk

Chocolate milk

Cheese

Ice cream

Yogurt

Other milk and dairy products

Meat and meat alternatives

Fats and sweets

If your child is 5 years of age or younger, does he or she eat any of these foods?

Parent / Guardian's Signature

First Name

Last Name

Choose how to sign

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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Bristol Public Schools

Pre-K Progam Application

Parents are:

Child's Developmental History. Please check that apply.

Do you have any concerns about your child's:

Please check all the words that make you think of your child:

Child's Race. Check all that apply:

Grains

Vegetables

Fruits

Milk and Other Dairy Products

Meat and meat alternatives

Fats and sweets

If your child is 5 years of age or younger, does he or she eat any of these foods?

Today's Date

Parent / Guardian's Signature