345 Mix Street,
Bristol, CT 06010
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Student's Full Name
Student's Date of Birth
Parent/ Guardian #1 Name
Parent/ Guardian #1 Address
Parent/ Guardian #2 Name
Parent/ Guardian #2 Address
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:
*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:
Nutrition Questionaire for Children
Which of these foods did your child eat or drink last week?
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?
Parent / Guardian's Signature