Greene County Tech Preschool 3 Year Old Program

In order for your child to be able to attend the Greene County Tech free 3 year old preschool program your child must be 3 years old on or before August 1st of that school year and meet one or more of the qualifications listed on qualifiers form in this packet. The preschool must receive the following items below, prior to your child attending preschool. Due to regulations that require these items, your child will not be able to attend until these items are on file with our preschool. Thank you for your cooperation and for your continued interest in your child's education.

The following must be turned in with this completed application Birth Certificate

*We must have a copy of the original paper document. No blue birth cards

Social Security Card

Insurance/Medicaid Card

Proof of Residency (electric bill, phone bill, etc. that has your street address)

*If you live with another family please indicate on application.

We will request these items during the SUMMER Current Immunization Record (must include all shots from birth)

EPSDT- Physical from doctor This screening is valid for only one year from the issue date. Necessary EPSDT Forms will be mailed to you during the summer

Proof of Income (Last month’s check stubs or last year’s W-2’s or

schedule C / F for self-employed) *We must have a total yearly income of each of the primary caregivers of the student living in the home.

On the first day of school your child will need to bring the following items: A change of clothes including underwear and socks

(Please, no pillows or stuffed animals) A large backpack (large enough for a winter coat) ** If you are unable to obtain these items, please notify our office and we will provide them for you.

WE NOW HAVE THIS APPLICATION AVAILABLE ON OUR WEBSITE: www.gctsd.k12.ar.us

If you have any questions or need information on how to obtain any of these items, please call: Kodie Potter- Asst. Principal 215-4470 215-5231 Fax

ONE OF THE FOLLOWING DOCUMENTS MUST BE SUBMITTED AS PROOF OF INCOME

(Income documents must show separate yearly household income for EACH primary caregiver living in the household.)

Most recent year’s Form W-2

If self-employed or farmers: most recent year’s Form 1040 Schedule C or F form

Recent pay stubs for each primary caregiver living in household (stubs dated within the last 30 days) **A month’s worth of stubs for each adult who is employed

Documentation showing current eligibility for food stamp benefits (Must be dated within 30 days of application.)

Letter from DHS caseworker verifying household income

If unemployed, a printout of your unemployment benefits

If disabled, a recent bank statement showing deposit of benefits or statement from Social Security

If homemaker, the notarized form must be filled out stating parent/guardian is a homemaker.

(see form in back of packet)

NEW STATE GUIDELINE REQUIREMENTS TO REMAIN IN SCHOOL ARE AS FOLLOWS:

3 year old

DTaP – 4 doses unless the 3rd dose has been in the last 6 months

Polio – 3 doses

Hib – 3 doses with last dose on or after 1st birthday

(Hib is not given after 3rd birthday)

HepB – 3 doses

MMR – 1 doses

Varicella – 1 doses

(Parental or physician note of disease is no longer accepted)

Pneumococcal – 3 doses with last dose on or after 1st birthday

Exemptions are granted by the Department of Health. To get an exemption parents must complete an application yearly for the shots they want to be exempt from. Exemptions can be obtained for medical, religious or philosophical reasons. A notarized statement by the individual requesting the exemption must accompany the application. Applications can be obtained by calling 501-661-2793 or online at the Arkansas State Board of Health website.

EPSDT (Physical) – includes a comprehensive physical & mental health

assessment and includes the following:

A complete physical exam

Immunizations

Testing blood for lead levels in younger children

Vision, Hearing, Dental series

In Arkansas doctors also assess a child’s nutrition, calculate his or her body mass index and offer nutrition advice

Kodie Potter

Asst. Principal

THE FOLLOWING APPLICATION MUST BE COMPLETED ENTIRELY.

Greene County Tech Early Childhood Registration Form

Date:_____________ Social Security #: ________ _______ _______ DOB ________________ Student’s Name: _____________________ ___________________ ______________________ (First) (Middle) (Last)

Name child goes by: ___________________ Race:__________ Sex: M / F Grade: 3yr or 4yr Primary Language: ________________ Secondary Language_______________ (if not English)

My child speaks English at home- YES / NO English Skills: very well / well / not well / not at all

____________________________________ _____________________ Parent/Guardian Signature Date

Street Address: _________________________________City: ___________________, AR Zip:__________ Housing (circle one): Own, Rent, Homeless, Other Date you started living at this address: _______________ Have you moved in the last 24 months? YES/NO Language Spoken at Home: ______________________ Home Phone: (____) _____ _______ Father Cell (____) _____ ________ Mother Cell (____) _____ ________

Mother/Step-Mother (or) Female guardian living at this address: Full Name: __________________________________________ Date of Birth: _____ _____ _____ Mother’s Primary Language__________________ Secondary Language (if not English)________________

Marital Status: Single/Married/Divorced Race: ___________ Place of Employment: _____________________________ Work Phone: (____) _____ _______ Employment Status: Employed Full Time/Self Employed/Homemaker/Farmer/Employed Part Time Education: Some High School, High School graduate, College Attending School: Full Time or Part Time ……………………………………………………………………………………………………………………………………

Father/Step-Father (or) Male guardian living at this address: Full Name: __________________________________________ Date of Birth: _____ _____ _____ Father’s Primary Language____________________ Secondary Language (if not English)________________ Marital Status: Single/Married/Divorced Race____________ Place of Employment: _________________________________Work Phone: (____) _____ _______ Employment Status: Employed Full Time/Self Employed/Homemaker/Farmer/Employed Part Time Education: Some High School, High School graduate, College Attending School: Full Time or Part Time

List All Other Household Members (Do not include child whose name appears at the top of this form)

Name

Relation Date of Birth Age School Attending (if applies)

List any relatives of the child named above that work for Greene County Tech School District

PLEASE COMPLETELY FILL OUT THIS QUALIFIERS FORM

Child’s Name: ___________________________________Date of Birth: __________________

Please circle “YES” or “NO” to ALL of the following: If yes to any of these you must provide documentation

YES/NO---Teenage parent (less than 18 yrs. of age) at time of child’s birth,

YES/NO---Foster Parent YES/NO---Grandparent YES/NO---Single Parent YES/NO---Student Parent YES/NO---Active Deployed Military Duty (_____Mother _____Father) YES/NO---History of Abuse or Neglect YES/NO---Foster Child YES/NO---One or more Parent Incarcerated (document needed from Police Dept.) YES/NO---Child lives with family member(s) other than biological parent(s) YES/NO---Low birth weight (5 ½ lbs. (8oz) or less) If “Yes” list birth weight ______ YES/NO---Parent without High School Diploma or GED (_____Mother _____Father) YES/NO---Drug or Alcohol abuse/addiction YES/NO---Developmental Delay: I suspect my child may be having problems in one or more of the following areas: (Please circle ALL suspected problem areas.) TALKING SEEING HEARING LEARNING WALKING BEHAVIOR YES/NO---English as a second language-(ESL) YES/NO---US Citizenship

YES/NO ---Mother is disabled YES/NO--- Father is disabled YES/NO---Income Eligible (see eligibility scale) I receive SNAP/Food Stamps (Circle One) YES/ NO

ABC INCOME ELIGIBILITY LEVELS

Family Size

ABC Eligible 200% FPL

1 $ 24,980.00 2 $ 33,820.00 3 $ 42,660.00 4 $ 51,500.00 5 $ 60,340.00 6 $ 69,180.00 7 $ 78,020.00 8 $ 86,860.00 9 $ 91,280.00

10 $ 95,700.00

____________________________________ _____________________ Parent/Guardian Signature Date

Number in family____ Number in Household____ Primary Caregiver yearly income ______________ Secondary Caregiver yearly income____________

Household yearly income____________

EARLY CHILDHOOD CONFIDENTIAL INFORMATION SOCIAL HISTORY

Child’s Name _______________________________________ Date ___________________ Age _______ Sex ________ Date of Birth___________________ SS# _______________________ Home Address _____________________________________Home Phone ____________________ Child lives with: ___Father ___Mother ___Both ____Guardian Name: ______________________________ Name: ____________________________________ Occupation: __________________________ Occupation: ________________________________ Work Phone __________________________ Work Phone ________________________________ Brothers/Sisters: Name Sex Age Grade Lives in home with the child ________________________________ _____ _____ ______ ____Yes ____No ________________________________ _____ _____ ______ ____Yes ____No ________________________________ _____ _____ ______ ____Yes ____No ________________________________ _____ _____ ______ ____Yes ____No Has child been treated for: Vision Loss? ___Yes ___No Hearing Loss? ___Yes ___No If yes, When? _________ Where? __________________ What were you told? _______________ Any problems: During pregnancy? __________ During Delivery? ______ Was labor induced? ______ List Birth Weight __________ Child’s health at birth: __________________________ As compared with other children, describe your child’s development. Indicate age at which your child: was weaned (bottle/breast) _________ crawled _________ walked around _________? sat alone_________ made sounds_________ Is your child toilet trained? Bowel __Yes__No Bladder __Yes__No Dry at Night __Yes__No Does your child use: Single words ____Yes ____No Sentences ____Yes ____No Phrases ____Yes ____No Say words clearly ____Yes ____No Is your child understood by mother? ____Yes ____No Is your child understood by others? ____Yes ____No Does your child have temper tantrums? ____Yes ____No If yes, describe ___________________ ________________________________________________________________________________ List your developmental concerns: _____________________________________________________ ________________________________________________________________________________ How does your child get along with other children? _______________________________________ How does your child get along with other adults? _________________________________________ Please describe your child’s personality (activity level, affectionate, shy, noisy, fearful, etc.) ________________________________________________________________________________ What does your child especially like to do or play with? ____________________________________ How does your child usually react to separation from you? __________________________________ Has your child been enrolled in nursery school or day care? ____Yes ____ No If yes, name & address of school or day care_____________________________________________

Has your child been diagnosed for treated for: ADD/ADHD ____Yes ____No

Allergies ____Yes ____No Asthma ____Yes ____No Cancer ____Yes ____No Cleft Palate ____Yes ____No Cerebral Palsy ____Yes ____No Diabetes ____Yes ____No Infections ____Yes ____No Operations ____Yes ____No Seizures ____Yes ____No Tubes/ears ____Yes ____No Other ____Yes ____No

If yes to any of the above, explain: ___________________________________________________ _______________________________________________________________________________ High fevers (104 degrees for higher): ___Yes ___No Duration: _________________________ Is your child on any kind of medication? ___Yes ___No If yes, name of drug _____________________ How often given__________________________

Complete info for any of the following with whom you have had contact concerning your child: Name Phone # City

☺ Pediatrician __________________________________________________________________

☺ Primary Care Doctor ___________________________________________________________

☺ Dentist ______________________________________________________________________

☺ Orthopedist __________________________________________________________________

☺ Ear, Nose, Throat Specialist _____________________________________________________

☺ Ophthalmologist ______________________________________________________________

☺ Surgeon ____________________________________________________________________

☺ Psychiatrist __________________________________________________________________

☺ Audiologist ___________________________________________________________________

☺ Speech Pathologist ____________________________________________________________

☺ Occupational Therapist _________________________________________________________

☺ Physical Therapist _____________________________________________________________

☺ Social Worker _________________________________________________________________

☺ Dietician, Nutritionist ___________________________________________________________

☺ Targeted/Certified Case Manager _________________________________________________

☺ Others (specify) _______________________________________________________________

PARENT/GUARDIAN SIGNATURE: __________________________________________

My child has medical Insurance-------YES/NO Name of Insurance___________________________ Child’s Medicaid eligibility-------------YES/NO Medicaid Number____________________________

GCT EARLY CHILDHOOD PROGRAMS DISCIPLINE POLICY

The Greene County Tech Preschool Programs use the following methods of discipline: Rewards, time-out, and loss of privileges are used to modify behavior. Children in conflict are redirected by staff to other activities or areas where they can calm down before time-out is administered. Children will spend no more than five minutes in time-out and will always be in full view of the classroom staff. Any specific discipline problems encountered will be shared with the child’s parent/guardian. Parents/guardians will be asked to participate in developing and implementing techniques to help modify the child’s behavior. Please note: The Greene County Tech Preschool Staff does not use corporal punishment (spanking) as a form of discipline. *I have read and understand the discipline policy of the Early Childhood Programs. I give my permission for the staff to use all methods mentioned above. __________________________________ ________________ Parent/Guardian Signature Date ******************************************************************************************************************* *If the parent/guardian disagrees with any discipline method stated above, please list the preferred: _____________________________________________________________________ _________________________________ __________________ Parent/Guardian Signature Date

PHOTOGRAPHY/VIDEO CONSENT

I give the Greene County Tech ABC staff permission to photograph or video my child throughout the school year while attending the ABC Preschool program.

_______________________________________________ Child’s Printed Name

_______________________________________________ Parent/Guardian Printed Name

______________________________________________ Parent/Guardian Signature

______________________ Date

BELOW (in front of Notary) THAT APPLIES TO YOU OR SKIP THIS PAGE IF NONE APPLIES The Greene County Tech Preschool office has a notary on staff for your convenience.

Date ______________________

I, _________________________am, employed part time / homemaker / retired /disabled /work for cash.

(your name) (circle option that applies)

My only source of income is from_________________. I make this amount weekly____________.

_____________________________________________

Signature ……………………………………………………………………………………………………………………………………

Date ______________________

I, _________________________am, unemployed and receive/do not receive unemployment benefits.

(your name) (circle one)

I received unemployment benefits in the amount of ____________ weekly/monthly. (circle one)

_____________________________________________

Signature ……………………………………………………………………………………………………………………………………

Date__________________ At the time this application was completed _________________________ lives with their (child’s name) Grandparent/Guardians which are not his/her biological parents.

____________________________ Signature

…………………………………………………………………………………………………………………………………

Date _______________________ At the time this application was completed I ________________________ verify that I have not (Print your name) graduated from high school.

____________________________ Signature

FOR NOTARY USE ONLY

_______________________________________________

Notary Signature & Date

STUDENT EMERGENCY CHECK OUT INFORMATION

In an attempt to protect your child while at school, the preschool will require photo identification on all persons checking out students. Unless this form is completed and on file with the classroom teacher, children will be checked out only by the biological parent as listed on the student’s birth certificate or to the child’s legal guardian. If you wish to allow another person to check your child out of school, please complete the form below and return it to school as soon as possible. In case of parental separation or divorce, we will allow a child to be checked out by either biological parent unless there is a copy of a legal document on file at school prohibiting that person from checking out the student. Please print all information below.

Student’s Name: ___________________________________________ Date: _________________

Please allow the following persons listed below to check the above named child out of school: (PLEASE LIST BIOLOGICAL and/or CUSTODIAL PARENTS ON LINES 1 & 2)

Name Relation to Student Work/Cell Phone/Pager # Home Phone #

1._______________________________________________________________________________ 2._______________________________________________________________________________ 3._______________________________________________________________________________ 4._______________________________________________________________________________ 5._______________________________________________________________________________ 6._______________________________________________________________________________

The following persons may NOT check my child out of school: Name Relation to Student

1._______________________________________________________________________________ 2._______________________________________________________________________________ 3._______________________________________________________________________________

Custody papers are on file with the school? YES NO PERSONS TO NOTIFY IN CASE OF AN EMERGENCY IF DIFFERENT THAN ABOVE: Name__________________________________ Phone ___________________________ Name__________________________________ Phone ___________________________ Name__________________________________ Phone ___________________________ _____________________________________________ ________________________ Signature of person completing this form Relation to child

PLEASE UPDATE THIS FORM A.S.A.P. IF ANY OF THE ABOVE INFORMATION CHANGES DURING THE SCHOOL YEAR

CONSENT FOR EMERGENCY CARE

I/We, _____________________________________________ (parent/guardian) of _____________________________________________ do hereby request and give (Child’s name) Permission for the GCT Preschool (Greene County Tech School District) employees in charge, to use their discretion in making decisions that will safeguard our child’s health and safety. Should questions arise regarding our child’s health or safety, the school may contact the physician and/or pharmacist. Any health condition concerning our child may be disclosed to all pertinent GCT staff that interacts with our child. If we cannot be contacted in an emergency, permission is given for the district’s appointed representative to receive such medical or surgical aid as may be deemed necessary and expedient by a dully licensed or recognized physician or surgeon. Consent is given to the duly appointed representative to transport our child for emergency medical treatment or to call for ambulance transportation if needed. As parents or guardians, we will assume medical fees and relieve school employees of all responsibility. _________________________________________ ______________ Parent/Guardian Signature Date PERSONS TO NOTIFY IN CASE OF AN EMERGENCY: Name__________________________________ Phone ___________________________ Name__________________________________ Phone ___________________________ Name__________________________________ Phone ___________________________ ____________________________________ ________________________ Signature of person completing this form Relation to child

Parents and/or Guardian, School Districts are not required to do a formal school choice for preschool students. However, GCT keeps data on the number of PK students that attend. Please fill out the following for our records.

1. Do you live in GCT District? Yes or No (circle one)

2. If No, what district do you reside? ____________________________

3. Why do you want your child to attend school at Greene County Tech?

________________________________________________________

4. Do you currently have any other children attending Greene County Tech?

Yes or No (circle one)

If yes, list names and grades _____________________________________ ______________________________________________________________

5. Do you have another child who has attended GCT on a school choice petition?

Yes or No (circle one)

6. Is your family new to Greene County Tech? Yes or No (circle one)

7. Would you be able to transport your child to school if bus transportation is not available?

Yes or No (circle one)

8. Has your child had any discipline problems at any prior schools?

Yes or No (circle one)

9. Does your child require any educational or medical special services?

Yes or No (circle one)

If so, please explain. _________________________________________

___________________________________________________________

NOTE:

If you do not reside in GCT School District and wish for your child to attend GCT in Kindergarten

you will need to file a School Choice Application by June 1 of the year they will enter

Kindergarten.

________________________________ _____________________ Parent/Guardian Signature Date

STUDENT NAME _______________________________