Date of Application
School Year You Are Interested In:
Child's Name:
Nick Name:
Name you would like your child to be called:
Child's Date of Birth:
Male
Female
Child's Address:
Street Address:
City:
State:
Zip:
Mother's Information
Mother's Name:
Mother's Email Address:
Mother's Address (if different than the child)
Street Address:
City:
State:
Zip:
Mother's Home Phone:
Mother's Work Phone:
Mother's Cell Phone:
Father's Information
Father's Name:
Father's Email Address:
Father's Address (if different than the child)
Street Address:
City:
State:
Zip:
Father's Home Phone:
Father's Work Phone:
Father's Cell Phone:
Please tell us about your child:
Family Information (please complete each box)
1. What was your child's birth weight?
2. How many members are in your household?
3. What is your annual household income? (required)
4. Is any parent/guardian unemployed?
Yes
No
5. Do any parents/guardians attend school or participate in job training programs?
Yes
No
6. If yes, where and how many credits?
7. Are you a single parent?
Yes
No
8. Has your child lost a parent to death or divorce?
Yes
No
9. Has your child lost a sibling due to death?
Yes
No
10. Were you a teenager when your first child was born?
Yes
No
11. Does your child have a chronically ill/handicapped parent or sibling?
Yes
No
12. Is either parent incarcerated?
Yes
No
13. Do you live in a rural or segregated area?
Yes
No
14. Does your child have a nutritional deficiency?
Yes
No
15. Does your child have a long term or chronic illness?
Yes
No
16. Does your child have a diagnosed handicap condition?
Yes
No
17. Does your child have a language deficiency?
Yes
No
18. Does your child have a destructive or violent temper?
Yes
No
19. Has your child had a lack of a stable support system
(moved a lot, parent in and out of home, etc.)?
Yes
No
20. Does either parent/guardian have a substance abuse or addiction problem?
Yes
No
21. Does either parent/guardian have a family history of low school achievement?
Yes
No
22. Does either parent/guardian have a family history of deliquency (trouble with law)?
Yes
No
23. Does either parent/guardian have a family history of diagnosed family problems?
Yes
No
24. Has your child been the victim of sexual or physical abuse?
Yes
No
What is the primary language spoken in the home?
Please enter the email address where you would like to receive the application confirmation: