There Is No Cost for Participation. Transportation Is Not Provided

Date Received: ______

_____Accepted Supporting School Readiness Program _____Waitlist Project Enlightenment • 501 S. Boylan Avenue • Raleigh, NC • 27603 Phone: 919-856-7774 Fax: 508-0810

Preschool Summer Program Application

Offered, June 15th-19th 2009 from 8:15a.m.-12:15p.m.daily. There is no cost for participation. Transportation is not provided. Children must be 5 on or before August 31st 2009 to participate and live in Wake County. Applications can be dropped off at school sites, mailed or faxed (both pages) through 5/11/09.

Child’s Name: ______

Locations: (check one) Aversboro Elementary Poe Elementary 1605 Aversboro Road, Garner 27529 400 Peyton Street, Raleigh 27610 662-2325 (phone) 662-2329 (fax) 250-4777 (phone) 250-4774 (fax)

Barwell Road Elementary Powell Elementary 3925 Barwell Road, Raleigh 27610 () 1130 Marlborough Road, Raleigh 27610 661-5405 (phone) 662-2111 (fax) 856-7737 (phone) 856-7749 (fax)

Brentwood Elementary Stough Elementary 3426 Ingram Drive, Raleigh 27604 4210 Edwards Mill Road, Raleigh, NC 27612 850-8720(phone) 850-8728(fax) 881-4950 (phone) 881-1422 (fax)

Cary Elementary Vandora Springs Elementary 400 Kildaire Farm Road, Cary, NC 27511 1300 Vandora Springs Road, Garner 27529 460-3455 (phone) 460-3550(fax) 662-2486 (phone) 662-5626 (fax)

Creech Road Elementary Wilburn Elementary 450 Creech Road, Garner 27529 3707 Marsh Creek Road, Raleigh 27604 662-2359 (phone) 662-2372(fax) 850-8738 (phone) 850-8780 (fax)

Millbrook Elementary York Elementary 1520 E. Millbrook Road, Raleigh 27609 5201 Brookhaven Drive, Raleigh 27612 850-8700 (phone) 850-8709 (fax) 881-4960 (phone) 881-1338 (fax)

Space is limited. Letters will be mailed on May 22nd letting families know if their child is accepted into the program. Families must confirm that their child will attend the program by June 1st in order to retain a space.

This program is funded by Wake County SmartStart, an organization that ensures children are prepared for success in school and in life. Please print clearly. Child Information: Name: ______Birthdate: ___ / ___ / ___ Address: ______City: ______Zip Code: ______

Contact Information: Mother: ______Telephone Number (H): ______Employer: ______(W) ______(Cell): ______Father: ______Telephone Number (H): ______Employer: ______(W) ______(Cell): ______

Does anyone in your household use any of the programs below: Yes No Medicaid WIC Childcare subsidy (includes waiting list) Free or reduced lunch More at 4 Health Choice

If no, are you eligible for these programs? Yes No (If you do not know, see the chart below. You may qualify if your income is below the amount listed for your family size.) Family Income Size Annual Monthly 1 $ 25,736.87 $ 2,144.74 2 $ 33,655.47 $ 2,804.62 3 $ 41,574.07 $ 3,464.51 4 $ 49,492.67 $ 4,124.39 5 $ 57,411.27 $ 4,784.27 6 $ 65,331.00 $ 5,444.25 7 $ 66,815.67 $ 5,567.97 8 $ 68,300.33 $ 5,691.69

Language you prefer to receive information in: English Spanish Other: ______

Medical Information Is your child currently taking daily medication? Yes NoIf yes, what? ______

Does your child have any allergies? Yes No If yes, what? ______

Questionnaire Has your child attended childcare and/or preschool? Yes No

If yes, where and how long did he/she attend? ______

Is your child registered for kindergarten? Yes No If yes, where? ______

Are you able to attend camp with your child on June 19th, 2009? Yes No

Please tell us anything else you would like us to know about your child below.

This program is funded by Wake County SmartStart, an organization that ensures children are prepared for success in school and in life.