Age: ______
Independence Integrated Preschool Program
Application for Preschool
Independence Local Schools
Preschool Children for the Independence Integrated Preschool will be chosen with the following considerations:
1. Must be a resident of Independence.
2. Must be at least 3 years of age prior to March 1, 2016 (and less than 6 years of age by August 1, 2016)
3. Strong communication and social skills are preferred.
4. Must be completely potty trained
For consideration for the 2016-2017 School Year, please complete this application and return it
NO LATER THAN JANUARY 29, 2016.
Identifying Data:
Child’s Name: _____________________________________________
Male
Female
Parents’ Name: ____________________________________________ Date of Birth: _______________________
Address: _________________________________________________ Phone Number: ______________________
_________________________________________________ Work/Cell:____________________________
Family History:
1.
Who lives at home with the child?
Names
Relationship to Child
Age
2. Are there any siblings or parents that live outside of the home?
No
Yes, Please indicate name, relationship, and ages of these individuals.
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Does your child
stay with a parent (mother or father) during the day?
attend day care during the day? Where? ________________Frequency? ____________
stay with a babysitter during the day?
4. Describe your child’s relationship with his/her siblings, if applicable _________________________________________
________________________________________________________________________________________________________
Developmental / Medical History:
1. Has your child ever received any Early Intervention Services (e.g., Help Me Grow, Speech Therapy, etc)?
No
Yes, Please describe the reasons for Early Intervention and the services provided.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
2. Is your child being treated for any persistent medical condition?
No
Yes, Please describe:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Application 2016-2017
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3. Please describe any complications during pregnancy, labor or delivery (including prematurity).
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Early Childhood Experiences:
1. Has your child attended preschool?
No, this will be his/her first preschool experience.
Yes, Please note where and when ___________________________
2. Please check and indicate approximate ages of participation and places for any of the following activities your
child has participated:
Library Storytime ___________________________________________________________________________
Parent Tot Music or Activity/Nature Classes _____________________________________________________
Toddler/Preschool Music or Activity/Nature classes (no parent) ____________________________________
Tot or Preschool Organized Sport Activities _____________________________________________________
Neighborhood or Preschool PTA playgroups _____________________________________________________
Other ______________________________________________________________________________________
Skill Development:
1. Please note any languages, other than English, that are spoken in the home. _________________________________
2. Can your child follow 2 step directions (e.g., put on your shoes and get your coat)?
Yes
No
3. Approximately how many words does your child understand?
100-200
> 200
4. How many words does your child put together in a phrase/sentence?
>100
3-5
5-8
8+
5. Do others have a difficult time understanding your child’s speech?
Yes
No
6. Can your child identify primary colors (red, yellow, blue)?
None
Some
Most/all
7. Can your child identify basic shapes (circle, triangle, square)?
None
Some
Most/all
8. Can your child identify numbers 1-10?
None
Some
Most/all
9. Can your child identify letters?
None
Some
Most/all
10.What play/leisure activities does your child enjoy? ______________________________________________________
Please indicate why you feel that the Independence Integrated Preschool Program would be a good match for your child.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Parent signature _________________________________ Date_______________________________________
Please return the completed application WITH A RECENT PHOTOGRAPH * to:
Independence Primary School
7600 Hillside Road
Independence, Ohio 44131
Attn: Stephanie VanDyke, Preschool Teacher
*Photograph to be returned with notification of screening results via mail by March 30, 2016.
Application 2016-2017
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