This section to be completed by Christina School District Staff Only

___Full Day ___ Newark MAC

Christina School District Preschool/Prekindergarten Montessori Program Application

Assurance of Confidentiality The information on this form will help us to deliver the best program for your child and provide supportive services your family may need. You may be asked to provide additional information and verifications before your child can be accepted into the program. The information you provide will be considered confidential and shared only with district staff.

Child's name: _________________________________________________________________ First Name Middle Initial Last Name Nickname: _________________________
Male Female

Date of Birth: ________________________

Parent/Guardian Name: ________________________________________ Address: ____________________________________________ ____________________________________________ ____________________________________________ Telephone Number(s): __________________________________________ Email Address: ________________________________________________ Child's primary language _______________Language spoken in the home: _________________
Please indicate the order of your preference by numbering the boxes:
Newark MAC Full Day Program: Monday - Friday 8:30-3:00 ($650 per month) Tuition Assistance Please check box if interested in applying for tuition assistance If applying for tuition assistance, please include the following documents: Four recent pay stubs Any letters of assistance
*Students may also apply for the Christina School District Early Education Program by completing and submitting a separate application. Enrollment space is limited in both the CSD Montessori Program and the CSD Early Education Program.

Has your child been identified as having, or suspected to have, a developmental delay or disability? Has your child ever received a developmental evaluation? Has your child ever received early intervention services?

yes yes yes

no no no

don't know don't know don't know

If yes, please identify where the services were received (home, center, hospital, etc.) and provide the name of the agency providing service: ______________________________________________________________________________ ______________________________________________________________________________ Do you or anyone else have any concerns about your child's health (physical and emotional) or behaviors?

yes

no

If yes, specify: _________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Does your child currently attend child care? yes no If yes, name of child care provider: _____________________________________________ Telephone number of child care provider: _______________________________ Does your family receive any of the following financial services? Medicaid/Medicare Childrens Health Insurance Program (CHIP) Supplemental Nutrition Assistance Program (Food Stamps) Public Assistance (TANF) WIC Supplemental Security Income Who receives this? __________________________________ Foster care/adoption subsidy Unemployment insurance yes yes yes yes yes yes yes yes no no no no no no no no

How many people are currently living in the home? _____ adults _____ children Name Relationship to Child Age/Birthdate

Does the applicant have an older sibling currently enrolled in a Montessori Program? If yes, please complete the following: Name of program: Name of student: Date of Birth: Grade: _________________________________ _________________________________ ___________________ ___________________

Interests/Needs Identification
Our Family and Community Services staff can provide parents with additional information that could be useful in the growth, well-being and success of children and families. We have information in our Family Resource Room on a wide range of topics that you may find helpful. If you have interests that are not included below, please list in the Other sections. This information is helpful in creating parent workshops and family activities that meet the interests and needs of enrolled families. Please indicate your level of interest for each of the following (If left blank, we will assume there is no interest):

1 = interested in more information 2 = interested in receiving services/referral

_____ Child Development _____ Child Care _____ Clothing _____ Child Abuse _____ Substance Abuse _____ Family Relationships _____ Child Support _____ Employment _____ Mental Health _____ Community Involvement _____ Domestic Violence _____ Transportation _____ Parenting Assistance _____ Energy Assistance (utilities) _____ Legal Services _____ Housing/Shelter _____ Incarcerated Individuals _____ Nutrition Information _____ Medical Care: child____ parent____ _____ Dental Care: child____ parent ____ _____ Adult Education (GED, High School Diploma, English as a Second Language) _____ Health Education & Prenatal Services _____ Other: ________________________________________________________________ _____ Other: ________________________________________________________________ ********** I understand that I will be asked to provide my childs birth certificate (original or legible copy), updated health form (within one year) with immunizations, and proof of residence (copy of lease or full page of electric bill) before my child can be considered for enrollment in preschool, prekindergarten or child care. If I am requesting tuition assistance, I will provide additional information and income verification as needed for eligibility. I certify that the information provided on this application is accurate and truthful to the best of my knowledge.

____________________________________ Parent/Guardian Signature ____________________________________ Childs Name Staff member assisting/accepting application:

________________________ Date

___________________________________ 3

REQUIRED DOCUMENTS *
1.

Birth Certificate (Official State Document; not Hospital Birth Record)

State Certificate of Live Birth Original preferred; good copy accepted Missing Birth Certificate State of DE Vital Statistics 302-283-7130-University Plaza-Chopin Bldg.or online - www.vitalchek.com (for all states)

2.

Medical Records
Immunizations and dates documented by a licensed healthcare provider. (Immunization Hotline 1800-282-8672) 5 or more doses of DtaP,DTP or DT vaccine( unless the 4th dose was given after the 4th birthday) 4 doses of IPV or OPV (unless 3rd dose was given after the 4th birthday) 2 doses of Measles ,Mumps and Rubella vaccine ( first dose after the age of 12 months, second dose after the 4th birthday) 3 doses of Hepatitis B vaccine 2 doses of Varicella vaccine (starting 2008-2009) or written documentation of disease from health care provider in lieu of vaccine. Physical exam: current , within two years Tuberculosis: Results of Mantoux TB Skin Test completed within the past 12 months or risk assessment as recommended by the Delaware Division of Public Health Children who enter Pre School and/or Kindergarten, or at age 5 shall be required to provide documentation of lead screening

3.

Custody or Guardianship (if applicable)

Original State of Delaware Family Court documents only Social Service Placement Letter (original)

4.

Proof of Residence (Must have parent/guardian name and address on the document) Current Electric Bill (service location must match mailing address)
Current, Valid, Signed and Dated Lease or Signed and Dated Settlement Statement Current rent receipt with property address and renter name Current utility bill (water, cable, phone, garbage, propane/oil) Current property tax or sewer bill Notarized Christina School District Residence Verification will be necessary if the proof of residence is not in the name of the parent/guardian.

5.

Picture ID of parent/guardian