Enrollment request on basis of: (check all that apply) Information

Splendora Independent School District
Aplicacion para el Programa de Prekindergarten
Estoy aplicando para el año escolar
Nombre del alumno(a):_______________________________________________________________________________________
Fecha de nacimiento: _______________________
(Debe cumplir 4 anos antes o el dia del 1 de septiembre del ano escolar. Se requiere documentacion)
Nombre del padre/guardian:____________________________________________ Telefono : ____________________________
Direccion para correo:_________________________________________________________________________________________
Direccion de la casa (si es diferente): _____________________________________________________________________________
Zona de residencia escolar: ____________________________________________________________________________________
Se verificara la informacion que en esta aplicacion. Si e determina que un alumno no es elegible despuedes de entrar en el programa,
no podra quedar en el programa.
Firma de padre/guardian: _______________________________________________
Fecha de aplicacion: ________________
Information below to be completed by school personnel
Enrollment request on basis of:
Limited English Proficient - Student does not speak or
comprehend the English Language.
Check appropriate box: Home Language Survey Completed
Oral Language Proficiency Test administered
Date: __________________ By: ___________________________
Results: ______________________________________________
Eligible? YES NO
Documentation on file? Yes No
Educationally Disadvantaged: Student is eligible to participate in
the National School Lunch/Breakfast Program.
Check the appropriate box:
Student is eligible for National School Lunch/Breakfast
Program
Total household size:_____________________________
Total monthly household income:___________________
ALL family members MUST be included:
Homeless: Student is homeless according to [42USC 1143(a)].
Check appropriate box:
The student lacks a regular, fixed or adequate nighttime
residence and/or
The student has primary nighttime residence that is a shelter
providing temporary living accommodations, an institution,
or a place not designated for or ordinarily used as a regular
sleeping accommodations for human beings.
Eligible?
YES
NO
Documentation on file?
Yes
Foster Child:
Student is a foster child or has been a foster child in the
custody of DFPS.
Eligible?
YES NO
Documentation on file? Yes No
(check all that apply)
OR
OR
Gross earnings (before deductions - wages, salaries, tips,
unemployment, compensations, Self-employed income, etc)
Payments from welfare, child support, alimony, pensions,
retirement, social security
Any other income (disability benefits, interest/dividends, etc.)
Family receives food stamps (not Lone Star)
Number: ________________________________________
Family receives TANF (formerly AFDC)
Number: ________________________________________
Eligible? YES NO
Documentation on file? Yes No
No
Member of the Armed Forces, State Military, or Reserved
Armed Forces Active or Activated
Eligible? YES NO Documentation on file? Yes No
OR
Member of the Armed Forces, State Military, or Reserved
Armed Forces Injured or killed while on active duty
Eligible? YES NO Documentation on file? Yes No
Special Education: Student qualifies for Special Education. This does not qualify the child for PK. The child must qualify in one of the
above areas. Has the student had an ARD? YES NO Special Education representatives signature: _______________________
Eligibility verified by: _____________________________________________________________________________________________
Position: _______________________________________________________________________________________________________
Parent notified by: ___________________________________________ Date: ______________________________________________
SISD PEIMS 7/2013