APPLICATION FOR PRE- Killeen Independent District

Please complete this application for Pre-K registration. Return this application to the school. (1) INFORMATION: Student ID#: Student Name School Name Grade Date of Birth Age

(2) PUBLIC ASSISTANCE: SNAP/Food Stamps/TANF Eligibility Group/Case # ______(3) Circle any that apply (documentation required): HEAD START HOMELESS LEP MIGRANT STAR OF TEXAS AWARD (4) FOSTER CHILD: ( CURRENT / PRIOR ) Has student ever been in the conservatorship (foster care) of the Department of Family and Protective Services (DFPS) following an adversary hearing?

(5) MILITARY DEPENDENT: ( YES / NO ) Is student the biological child, adopted child or step child of a military member who is on active duty, is MIA or was injured or killed during active military duty (includes activated Texas National Guard and all activated Reserves)?

(Section 6 below is only required if student is qualifying based on income) (6) HOUSEHOLD MEMBERS AND MONTHLY INCOME:

(Proof of income must cover the entire previous calendar month.) Other No Income No Income Gross Monthly Earnings Monthly Names of Household Members (before deductions) Income Total

(list names of all adults and children (welfare, Monthly pensions, Income who live in this household) retirement, Job 1 Job 2 Social Security,  etc.) $ $ $ $

Total Household Monthly Income: $

(6) SIGNATURE: I certify that all of the above is true and correct and that all income is reported (if required). I understand that this information is being given for the receipt of funds, that school officials may verify the information on the application and that deliberate misrepresentation of the information may subject me to prosecution under applicable state law.

X ______Date: ______(Signature of Adult Household Member) For School Use Only Do Not Write Below This Line

Approved ______(ADA eligible) Military Income/Head Start Language Homeless Foster Care Migrant Star of Texas

Disapproved ______(not enrolled) Military Income/Head Start Language Homeless Foster Care Migrant Star of Texas

ARD Placement ______(ADA ineligible) Family Number: ______

KISD No. 285-870 Rev: July 2017 PREKINDERGARTEN ELIGIBILITY CHECKLIST

ID#: ______Student Name: ______Campus: ______

Parents - Please Do Not Write Below This Box For School Use Only

District personnel check all that apply:

Copy of Social Security Card (on file)

Copy of Birth Certificate or other acceptable documentation of name and birth date (on file)

Age Verification: Must be three (3) on or before September 1 for 3 yr old program Must be four (4) on or before September 1 for 4 yr old program

Address Verification for 3 yr old program: Must reside in on-post housing & in the attendance zone of the school they will attend, unless a special transfer is approved

Eligible for Pre-K: Student is the biological child, adopted child or step child of a Military member who is on active duty, is MIA or was injured or killed during active military duty (includes activated Texas National Guard and all activated Reserves). Documentation must be attached to Pre-K Application. Military ID: ______/______(Expiration Date) (verified by: Printed Name / Signature / Date) Eligible for Pre-K: Student is Economically Disadvantaged (eligible for free/reduced lunch) -- Income and/or other appropriate documentation must be attached to Pre-K Application

Eligible for Pre-K: Student is LEP (Limited English Proficient) if all the following are true:  Home Language Survey (HLS) indicates a language other than English (on file)  Qualifying score on OLPT  LPAC has identified the student as an English language learner

Eligible for Pre-K: Student is enrolled as a participant in Head Start (documentation required)

Eligible for Pre-K: Student is “homeless” (Residency Questionnaire must be completed)

Eligible for Pre-K: Student is considered “migrant” (Family Survey must be completed)

Eligible for Pre-K: Student has ever been in the conservatorship (foster care) of the Department of Family and Protective Services (DFPS) following an adversary hearing (documentation must be attached to Pre-K Application); PEIMS coding depends on Current or Prior foster care status.

Eligible for Pre-K: Student’s parent is eligible for or a recipient of a Star of Texas Award

Eligible for Pre-K on previous KISD campus this year: verify documentation (student must re- qualify for Pre-K if withdrawn from the District for more than 1 full school day; contact PEIMS office for extenuating circumstances or other exceptions)

Official Free & Reduced Meal Application has been completed (on-line or forwarded to Food Service by the Campus) -- All qualifying Pre-K must complete an application, excluding students qualifying as homeless, foster, migrant, direct certified households or students enrolled at CEP campuses.

PEIMS Pre-Kindergarten (Program) and Pre-K Eligibility Criteria screens have been completed for eligible Pre-K student

Student is not eligible for Pre-K but ARD has placed student in Pre-K classroom

Student is not eligible for Pre-K and will not be enrolled

Principal Signature: ______Date: ______

KISD No. 285-880 Rev: August 2018