There Is No Cost for Participation. Transportation Is Not Provided

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

1605 Aversboro Road, Garner 27529

662-2325 (phone) 662-2329 (fax)

Barwell Road Elementary

3925 Barwell Road, Raleigh 27610 ()

661-5405 (phone) 662-2111 (fax)

Brentwood Elementary

3426 Ingram Drive, Raleigh 27604

850-8720(phone) 850-8728(fax)

Cary Elementary

400 Kildaire Farm Road, Cary, NC 27511

460-3455 (phone) 460-3550(fax)

Creech Road Elementary

450 Creech Road, Garner 27529

662-2359 (phone) 662-2372(fax)

Millbrook Elementary

1520 E. Millbrook Road, Raleigh 27609

850-8700 (phone) 850-8709 (fax)

Poe Elementary

400 Peyton Street, Raleigh 27610

250-4777 (phone) 250-4774 (fax)

Powell Elementary

1130 Marlborough Road, Raleigh 27610

856-7737 (phone) 856-7749 (fax)

Stough Elementary

4210 Edwards Mill Road, Raleigh, NC 27612

881-4950 (phone) 881-1422 (fax)

Vandora Springs Elementary

1300 Vandora Springs Road, Garner 27529

662-2486 (phone) 662-5626 (fax)

Wilburn Elementary

3707 Marsh Creek Road, Raleigh 27604

850-8738 (phone) 850-8780 (fax)

York Elementary

5201 Brookhaven Drive, Raleigh 27612

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.

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 Size / Income
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 No If 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.