Family Information

Mother's Name *

Mother's Cell Phone *

Mother's Email Address *

Mother's Employer *

Mother's Work Phone *

Average Monthly Income for Mother *

Number in Mother's Household *

Family Information for mother (or custodial guardian)

Child lives with: *

Has your child attended any other Head Start or preschool programs previously? If so please list

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Family Information

Father's Name *

Father's Cell Phone *

Father's Email Address *

Father's Employer *

Father's Work Phone

Average Monthly Income for Father *

Number in Father's Household *

Family Information for Father (or custodial guardian)

If families enroll a child in preschool at the same time, in two different school districts, then those families may be responsible for paying tuition to one of those districts.

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Emergency Contact Info

Emergency Contact Name *

Emergency Contact Place of Work *

Emergency Contact Address *

Child's Doctor *

Doctor's Phone Number *

Doctor's Address *

Child's Dentist *

Dentist's Phone Number *

Dentist's Address *

People with Permission to Pick Up *

Pick up Name, Relationship, & Phone Number
Pick up Name, Relationship, & Phone Number
Pick up Name, Relationship, & Phone Number
Pick up Name, Relationship, & Phone Number

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We are asking the following questions to help us better meet your child’s needs. Please be assured that his information will not be shared with anyone besides your child’s teacher.

Child's Birth Weight

Was your child full-term? *

Yes

If no, how many weeks premature?

Were there any medical issues at delivery or shortly thereafter? Please explain *

Has your child experienced any other medical issues (other than typical colds)? If yes, please describe: *

Please list and explain any allergies your child has.

Please describe any history of learning problems in family.

Do you have any concerns about your child’s development? If so please describe *

Has your family experienced any recent changes such as: moving, births, deaths, divorce, unemployment. If so please describe: *

Is your family affected by any major stresses such as: military deployment, immigration, loss of a parent or disability? If so, please describe: *

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What is the mother’s level of education: *

Was her overall school experience: positive, negative or neutral? *

What is the father’s level of education: *

Was his overall school experience: positive, negative or neutral? *

Names and ages of family members in the home: *

Does your family have health insurance or other funding for medical care? What type? *

Are you an ASU Student: *

Yes

Are You ASU Faculty or Staff: *

Yes

If yes, what Department at ASU?

Is your Child in: *

Diapers

Transitioning

Fully Potty Trained

If in Diapers- Diaper Brand:

Diaper Size:

How many hours of weekly care are you requesting (all requests are subject to availability) *

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Parent Participation Form

Family participation is vital to any education program. Our goal is to have each family participate in at least one activity each month. Below is a list of ways you can participate in your child's education. Please check any way you can help.

Ways to participate

I can visit the classroom to tell about my occupation, help with an art activity, share my culture, read a story, or just enjoy the day with my child.

I can volunteer for fieldtrips

I will participate in Parent Teacher Conferences

I can attend school education/social events. (When possible, we have family nights once a month, and we have family events during the day.)

I can participate in home visits.

I am interested in lunches and/or breakfasts that may be held at the school for families.

My child has other family members who would enjoy attending events or volunteering (for example Grandma, Grandpa, Aunt, Uncle, or older brothers or sisters, etc.)

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Please Upload the Following Requirements

Please upload your Child's Immunization Record *

Immunization Record

Please upload your child's Birth Certificate *

Birth Certificate

The following forms are required to submit an application for enrollment. Simply visit https://www.gingerbreadcenter.org/faq and print out the required forms. Fill them out, sign them, and upload them to this application. You can take a photo or scan in the forms.

Please upload a physical exam form filled out by a health provider (optional at this time, but due within 30 days after your child begins)

Physical exam certificate

Please Upload the Preventative Creams and Ointments Permission Form *

Preventative Creams and Ointments

Please Upload the Emergency Medical Authorization Form *

Emergency Medical Authorization

Please upload the Parent Handbook Receipt and Acknowledgement Form *

Parent Handbook Receipt and Acknowledgement

Please Upload the Permissions Form (Video Tape, Photo, Field Trip, Screenings) *

Permissions for Video Tape, Photo, Field Trip & Screenings

Please upload the Income Eligibility for Child Care form (provides reimbursement for meals and snacks) *

Income Eligibility

If your child has allergies, please upload a completed Allergy Form signed by a physician (optional)

Allergy Form

If your child requires a special diet, please upload the Special Diet Form (optional)

Special Diet

By submitting this application, I understand that I have given full and accurate information on this application.

I understand

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