Preschool Application 2021-2022

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Cleveland County Schools 2021-2022 Preschool Application

Child’s Legal Name*
Date of Birth*
Gender*
Ethnicity (must choose one)*
Is your child a U.S. Citizen?*
Is your child a resident of North Carolina?*
Is your child a resident of Cleveland County?*
Race ( Check all that apply)*
Parent Name (or) Legal Guardian:*
Living Address*
Is your mailing address the same as your living?*
Mailing Address*

About your Child

Does your child speak English as a first language?*
Does the parent(s) speak English as a first language?*
Has your child been diagnosed as disabled or having special needs?*
(If yes, attach documentation)
No File Chosen
File uploads may not work on some mobile devices.
Does your child have an Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP)?*
Does your child have any diagnosed health problems or allergies:*
Has your child ever been enrolled in childcare or preschool?*
When?
Is your child currently enrolled in child care or preschool?*
Was your child enrolled as a 3 year-old in the same center/site you are applying for now?*
Has your child ever received any of the following services?*
Is your family currently receiving any of the following services?*

ABOUT YOUR FAMILY MEMBERS AND HOUSEHOLD (Circle member on each line)

Is the child’s mother/guardian employed?*
Is the mother/guardian looking for employment?

The mother/guardian must complete an Unemployment Form. 

Is the child’s father/guardian employed?*
Is the father/guardian looking for employment?

The father/guardian must complete an Unemployment Form

Is at least one parent or guardian of this child an active member of the military, or was a parent or guardian seriously injured or killed while on active duty?*
Are other children in the household receiving free or reduced school lunch?*
Who does the child live with?*
Parents/Guardians are:*

List everyone who lives in your home (alongside of your child) and their relationship to the child.

please list All parents wholive with the child

Resident Name*
Date of Birth*
Resident Name
Date of Birth
Resident Name
Date of Birth
Resident Name
Date of Birth
Resident Name
Date of Birth
Mother/Guardian education level:*
Is Mother/Guardian currently enrolled in
Father/Guardian education level:*
Is Father/Guardian currently enrolled in

Family Income – Check all that apply. Submit proof of income for all selected sources.

Family Income*
$
$
$

Additional Contact Information. Persons listed below will be contacted if we are unable to contact you.

Name*
Name
Permission to Publish Consent*
  • I understand that by filling out this application and going through the screening process that my child will be considered for a preschool class in the Cleveland County Schools. 
  • This application process does not guarantee my child a slot in a preschool class. Preschool slots are limited. 
  • I understand that if my child is chosen for a school placement outside my zone, I will be responsible for providing daily transportation. 
  • I further understand that all paperwork must be completed in its entirety and received at the OSR prior to my child’s placement. 
  • A current physical must be on file within 30 days of enrollment or my child cannot attend school. 
  • I understand that the Office of School Readiness must be notified of any changes to the application or my child’s application process will be interrupted until information is received. 
  • I understand that if my child has a doctor diagnosed condition that requires medical forms or medication, these forms and the medication will be turned in to the Office of School Readiness prior to their first day in school. 
  • I hereby certify that, to the best of my knowledge, all information on this application is correct. 
  • I understand that by falsifying documents my child could lose their spot if placed. 
  • Upon accepting a slot, I agree to follow all program regulations. 
  • I hereby authorize that my child be given an educational, social-emotional, and health screening for the purpose of meeting guidelines for the Cleveland County Preschool Program.
Name*

NUTRITION ASSESSMENT

Where does your child usually eat breakfast Monday-Friday? *
What type of milk does your child drink?*
Does your child take an iron supplement?*
Does your child take a multivitamin?*

Child’s Medical / Dental/ Insurance Record

Please check any medical condition past or current that your child has had. A Medical Documentation MUST be provided from your doctor's office.*
Additional Concerns
Allergies*
Please check any milk allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Please check any egg allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Please check any peanuts allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Please check any wheat allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Please check any tree nuts allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Please check any soy allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Please check any latex allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Please check any insects allergy or intolerance your child has. Check the reaction type. Medical Documentation MUST be provided from your doctor's office.
Is your child on any medication (prescription or over the counter)?*
Did your child have any medical problems at birth? *
Has your child ever been hospitalized, had a serious illness or accident?*
Has your child ever been treated or examined by a dentist?*
Is your child potty trained?*
Please check any services your child has received or is currently receiving & where they received it.
Please check all types of insurance your child has:*

Social Emotional Questionnaire-Preschool Screenings / My Teacher Wants to Know

** Please fill out to the best of your knowledge.

Child's Name*
Parent's Name*
Have you had any other children attend CCS Preschool Programs?*
If so, please list their name(s)*
Has Attended Daycare*
Responds to/ follows simple directions*
Engages in play with other children*
Takes Turns*
Shares With Others*
Easily Distracted*
Expresses his/her feelings to others*
Quiet, Shy*
Easily overwhelmed or Frustrated*
Talkative*
Energetic/On the Go*
Independent: Likes to do tasks on his/her own*
Enjoys playing outside*
Rest/Takes a Nap*
Puts things in his/her mouth (non-edible)*
Distressed by loud noises*
(e.g., food allergies, sensitivities, triggers, challenges, talents, sensory issues, sleep patterns, diet, skills/strengths, number of siblings in the home and their ages, involvement in extracurricular activities, etc.) ________

Environmental Checklist- REQUIRED

Please check any of the following that apply to your child and add comments if needed:*
Please Check the box by your current living situation*
I Have moved in the last 12 months?*
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