GSRP Online Application

Child's First & Last Name *

Child's Date of Birth *

Child's Current Age *

Phone Number *

Child's Birth Place *

Mother's First & Last Name *

Mother's Mailing Address *

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Line 2

City

State

Zip Code

Country

Mother's Phone Number *

Father's First & Last Name *

Father's Mailing Address *

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Line 2

City

State

Zip Code

Country

Father's Email *

Father's Phone Number *

1. Family Income: annual before taxes (include all wages, child support, unemployment, SSI, Social Security, alimony & all other *

2. Diagnosed Disability or Identified Developmental Delay (for child) *

low birth weight child immature nutritionally deficent IEP (Individualized Education Plan) child has long term or chronic illness referral by doctor, ISD or parent for screening speech difficulties, difficult to understand, difficulty expressing needs, does not speak in whole sentences none other

3. Child Behaviors *

child is destructive or violent child in counseling or therapy or referred child has been asked to leave a preschool or childcare center none other

4. Child's Primary Language is... *

English Not English English & another language

5. Parent/Siblings Educational Attainment *

Parent (s) or older siblings cannot read Parent (s) or older siblings have dropped out of school Parent (s) of older siblings struggled in school. May have received or are currently receiving special services none other

5. Mother's Highest Educational Level *

less than 12th grade high school graduate (or GED) technical training college (some or completed)

5. Father's Highest Educational Attainment *

less than 12th grade high school graduate (or GED) technical training college (some or completed)

6. Abuse, Neglect in Home *

someone in our home was a victim of physical, sexual or emotional abuse or neglect there is a history of substance abuse in our family (alcohol, drugs, prescription drugs, etc.) someone in our home has a violent and/or destructive temperament none

My Child's General Health is... *

excellent good fair frequently ill

List any medications your child is taking *

Total number of people living in your child's home. List names, ages & relationship to child people living in the home *

Comment *

List names, ages & relationship to child for all family members living outside of family home (parents, siblings, half-siblings, step-siblings) *

Comment *

Did the child's birth mother receive regular medical care during pregnancy *

Yes No other

Biological Child? *

Yes No

Were there any problems/complications at birth (mother or child) *

Yes No

Was there any substance use (alcohol, drugs, tobacco) during pregnancy by mother or father? *

Yes No

Child's Hair Color *

Child's Eye Color *

Child's Height *

Child's Weight *

Does your child have any allergies (food, bee stings, medicine) *

Yes No

Comment *

Does your child have any limitations or conditions we should be aware of? *

Yes No

Comment *

I am aware that by completing this application it can be submitted to HeadStart, ISD, or Royal Oak Schools for enrollment consideration. I understand the services unique to each preschool program. I understand the opportunities, services or benefits may differ and I may not receive some services based on my choices *

select to initial

I certify that the information on this application is true and accurate to the best of my knowledge *

select to initial

I allow Royal Oak Schools GSRP preschool permission to use photographs of my child for educational or program promotion *

Yes No

Parent or guardian signature (type full name) *

Royal Oak GSRP Online Application

Child's Information

Mother's Information

Father's Information

Family Information

Child's General Information

Pregnancy & Birth Information

Check boxes below to give Royal Oak Schools consent for the following...