Preschool Intake Form Part I: Child And Family Information - Medford Public Schools (Page 2 of 2) in pdf

Preschool Intake Form Part I: Child And Family Information - Medford Public Schools Page 2

START DATE: ____/____/____

Child’s Name: _______________________________________

Parent/Guardian #2

Name: __________________________ Relationship to Child: ____________

Living in same household with child?

Yes

Address:_____________________ City/State/Zip:____________________

Home Telephone #:_______________________ Work Telephone #:_______________________

Cell Phone #: ________________________ Email Address: ________________________________________

Employment:

Employed full-time

Unemployed

Child Support

Employed part-time

Retired

Disabled

Other______________________________

Parent/Guardian’s disability, if any:____________________________________

Other Children in Household

List names and ages of siblings (oldest to youngest). Also list any other members that live in

your household.

Name:

Date of birth:

Age in years:

Program name:

PLEASE RETURN THIS FORM WITH ALL INCOME DOCUMENTATION INCLUDING:

FOUR (4) CONSECUTIVE PAY STUBS FROM ALL WORKING PARENTS

MEDFORD PUBLIC SCHOOL, EARLY CHILDHOOD OFFICE,

489 WINTHROP STREET, MEDFORD, MA 02155

781-393-2102

Fax – 781-393-2123

calpers@medford.k12.ma.us

Preschool Intake Form Part I: Child And Family Information - Medford Public Schools Page 2