Great Start Readiness Preschool (GSRP)
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Royal Oak GSRP Online Application
Child's Information
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Indicates required field
Child's First & Last Name
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Child's Date of Birth
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Child's Current Age
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Child's Gender
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Male
Female
Phone Number
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Child's Birth Place
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Racial/Ethnic Data
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American Indian
Asian
African American
Hispanic
Caucasian
Multi-Racial
I prefer not to identify
Parent 1 Information
(main contact for enrollment purposes)
Parent 1 First & Last Name
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Parent 1 Age
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Parent 1 Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Parent 1 Phone Number
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Parent 1 Email
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Parent 1 Employer
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Parent 2 Information
Parent 2 First & Last Name
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Parent 2 Age
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Parent 2 Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Parent 2 Email
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Parent 2 Phone Number
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Parent 2 Employer
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Current Marital Status
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Single
Married
Re-Married
Divorced
Separated
Widowed
Living Together
Family Information
1. Family Income: annual before taxes (include all wages, child support, unemployment, SSI, Social Security, alimony & all other
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Comment
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2. Diagnosed Disability or Identified Developmental Delay (for child)
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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
Is your child potty trained?
none
other
Comment
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3. Child Behaviors
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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
Comment
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4. Child's Primary Language is...
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English
Not English
English & another language
Comment
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5. Parent/Siblings Educational Attainment (birth parent/family information part of eligibility factors)
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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
Comment
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5. Mother's Highest Educational Level (birth parent/family information part of eligibility factors)
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less than 12th grade
high school graduate (or GED)
technical training
some college
completed degree (associates/BA+)
5. Father's Highest Educational Attainment (birth parent/family information part of eligibility factors)
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less than 12th grade
high school graduate (or GED)
technical training
some college
completed degree (associates/BA+)
6. Abuse, Neglect in Home
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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
Comment
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7. Environmental Factors (may be birth family history or current home life)
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I am a single parent
someone in our home is/was in jail or prison
my child has experienced the loss of a parent or sibling by death, divorce, military service or out of town employment
my child has a chronically ill parent or sibling ex: behavior issues, physical, mental or emotional illness or disability (ADD/ADHD/depression/bi-polar/Autism etc.)
teenage parent at birth of any children
child is/has been in foster care
we have moved more than 3 times in 2 years
we are living with family/friends/shelter
our home is or may be in foreclosure
unemployed parent (s)
none
other
Comment
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Child's General Information
My Child's General Health is...
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excellent
good
fair
frequently ill
Comment
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List any medications your child is taking
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Total number of people living in your child's home. List names, ages & relationship to child people living in the home
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Comment
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List names, ages & relationship to child for all family members living outside of family home (parents, siblings, half-siblings, step-siblings)
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Comment
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Pregnancy & Birth Information
Did the child's birth mother receive regular medical care during pregnancy
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Yes
No
other
Comment
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Biological Child?
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Yes
No
Were there any problems/complications at birth (mother or child)
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Yes
No
Comment
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Was there any substance use (alcohol, drugs, tobacco) during pregnancy by mother or father?
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Yes
No
Comment
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Please check all of the services your family is receiving
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therapy (speech, OT, PT)
aggression management
counseling
alcohol and/or drug services
parenting classes
WIC
food stamps/Bridge Card
SSI
child protective services
special education services (ISD)
Early-On services
Early Head Start (0-3)
readiness groups (ISD)
child care services
none
other
Comment
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Child's Hair Color
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Child's Eye Color
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Child's Height
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Child's Weight
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Does your child have any allergies (food, bee stings, medicine)
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Yes
No
Comment
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Does your child have any limitations or conditions we should be aware of?
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Yes
No
Comment
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Check boxes below to give Royal Oak Schools consent for the following...
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
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select to initial
I certify that the information on this application is true and accurate to the best of my knowledge
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select to initial
I allow Royal Oak Schools GSRP preschool permission to use photographs of my child for educational or program promotion
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Yes
No
Parent or guardian signature (type full name)
*
Submit
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Contact
Curriculum & Learning
Kindergarten Enrollment
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Parent Handbook