Indy ELC Application for 26-27 School Year
Free Developmentally-Appropriate Preschool offering two sessions, Monday-Friday. AM Session: 8:00am-11:00am. PM Session- 12:30pm-3:30pm (early dismissal 2:45 every Weds). Breakfast & lunch available. Children must be either 3 or 4 years of age on or before August 31 but cannot have reached their 5th birthday. Once this application is submitted, Indy ELC will contact you with further information. Please note that you will be required to fill out a Child & Adult Care Food Program (CACFP) form for USD 446 food services, which will be available at district enrollment in August. School supply lists are available on our website, www.indyschools.com
Student's Name:
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Student's Date of Birth:
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Gender:
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Choose One
Male
Female
Student is applying for:
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Choose One
3-year-old Class (DOB is between 09/1/22-08/31/23)
4-year-old Class (DOB is between 09/1/21-08/31/22)
Preferred Session (not guaranteed):
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Choose One
AM 8:00-11:00am
PM 12:30-3:30pm
No Preference
What is the primary language spoken in the household?
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Is the student toilet-trained?
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Choose One
Yes
No
Does the Student have an IEP or IFSP through Tri-County?
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Choose One
Yes
No
Does the student have any allergies or medical needs?
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Students meeting At-Risk criteria may get priority. Please choose ALL that apply:
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A
Family in Poverty
B
Single Parent Household
C
Foster care or Kansas Department for Children and Families (DCF) referral
D
Teen Parents. At least one parent was a teenager (19 or younger) when the child was born.
E
Either parent is lacking a high school diploma or GED.
F
English Language Learner
G
Developmentally or academically delayed based on a scored and validated assessment
H
Child qualifies for migrant status
I
Family experiences chronic or episodic homelessness
J
*Does not meet any At-Risk criteria
Choose ALL that apply.
Primary Guardian Information:
Primary Guardian's Name:
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Guardian's DOB:
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Guardian's Email:
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Guardian's Phone:
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Marital Status:
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Choose One
Single
Married
Separated
Divorced
Highest Level of Education:
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Choose One
High School Diploma
GED
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Other
Guardian's Address (student's primary address):
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Address Line 2 (optional)
City
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State/Province
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Zip Code/Postal Code
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Is the Student currently in Foster Care? (If Yes, you can skip the Income Information section)
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Choose One
Yes
No
How many people live in the household?
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REQUIRED: List ALL household members below. The application is not considered complete if left blank:
Enter Household Income Information:
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List ALL Household Members
Household Member's DOB
Member's YEARLY Earnings From Work
Other YEARLY Regular Income (social security, child support, welfare, alimony, etc)
Check Here if Member's Income is ZERO
By typing your name below, you confirm that the information provided in this application is accurate and complete to the best of your knowledge.
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Today's Date:
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