Pre-Enrollment Form | Children Of Promise

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone Number (Enter Phone Number after the +1 without any hyphens.)

Please provide the names and ages of the child/children you are considering enrolling at Children Of Promise.

Income: We are required by the state to retain Household Income in our files and to determine if family qualifies for free daycare through brightpoint.

Please check any public benefits that you recieve:

WIC

Medicaid Card

SNAP

TANF

CCAP

Is your family experiencing homelessness ? (Yes or No)

Does the child have an IEP or have they bee referred for special education evaluation? (Yes or No)

Has the primary caregiver completed high school/No GED? ? (Yes or No)

Was the parent a teen at birth or or they currently under 21? ? (Yes or No)

Child was born outside of the United States or has one or more parent or caregiver born outside of the United States? (Yes or No)

Is the child a foster child or adopted? (Yes or No)

Was the child was born outside of the United States or has one or more parent or caregiver born outside of the United States? (Yes or No)

Does the parent or caregiver primarily speak a language other than English at home? (Yes or No)

Is either one of the child's parents an active military service member? (Yes or No)

Has the child previously partcipated in a formal early learning program? (Yes or No)

Is the family currently receiving Brightpoint childcare subsidies? (Yes or No)

Is the child currently living with both parents or a single parent? (Yes or No)

Is the child currently enrolled in early intervention or do they have a sibling who is enrolled in early intervention or special education? (Yes or No)

Has the child experienced any history of abuse, neglect, or domestic violence ? (Yes or No)

Are any members of the household experiencing mental illness, chronic, or terminal illness? (Yes or No)