ABC Preschool Application

Primary Caregiver Information

Primary Caregiver Name(Required)
MM slash DD slash YYYY
Gender(Required)
Food STAMPS(Required)
MARRIED(Required)
Primary Caregiver Address(Required)
Have you moved in the last 24 months?
Current Housing(Required)
Education Status(Required)
Employment Status
*EMPLOYMENT ELIGIBILITY DOCUMENTATION REQUIRED:

Demographic Information

Ethinicity
Hispanic
Race
IS THERE A SECONDARY CAREGIVER IN THE HOUSEHOLD?
If Yes, complete the secondary caregiver information
I DECLARE UNDER THE PENALTY OF PERJURY AND THE RULES AND REGULATIONS OF THE ARKANSAS BETTER CHANCE PROGRAM THAT THE INFORMATION SUPPLIED IS TRUE AND CORRECT AT THE TIME OF APPLICATION. I UNDERSTAND THAT THE INFORMATION I SUPPLIED MAY BE INDEPENDENTLY VERIFIED BY THE ARKANSAS DIVISION OF CHILD CARE AND EARLY CHILDHOOD EDUCATION AND THAT ANY FALSE STATEMENTS MAY RESULT IN EXCLUSION FROM DHS PROGRAMS AND CRIMINIAL PROSECUTION.
MM slash DD slash YYYY
I UNDERSTAND THAT MY CHILD MAY BE SUBJECT TO INTERVIEWS BY DHS LICENSING STAFF, CHILD MALTREATMENT INVESTIGATORS, AND/OR LAW ENFORCEMENT OFFICIALS FOR THE PURPOSE OF DETERMINING LICENSING COMPLIANCE OR FOR INVESTIGATIVE PURPOSES. CHILD INTERVIEWS DO NOT REQUIRE PARENTAL NOTICE OR CONSENT. CHILDREN MAY BE INTERVIEWED INDIVIDUALLY OR IN A GROUP. I UNDERSTAND THAT LICENSING COMPLIANCE FORMS ARE AVAILABLE FOR REVIEW UPON REQUEST.
Date 2

Secondary Caregiver Information

Only used when there is a secondary caregiver in the household.
Secondary Caregiver Name
SC Today's Date
Gender
SC Birthday
SC Education Status
SC Employment Status
* SC EMPLOYMENT ELIGIBILITY DOCUMENTATION REQUIRED:

SC Demographic Information

SC Ethnicity
Hispanic
SC Race
ARKANSAS BETTER CHANCE PRESCHOOL FOR SCHOOL SUCCESS ELIGIBILITY APPLICATION REQUIRED DOCUMENTATION TO BE SUBMITTED: • INCOME (30 DAYS) FOR PRIMARY AND SECONDARY CAREGIVER(S) • COPY OF PRIMARY CAREGIVER’S SOCIAL SECURITY CARD. • COPY OF THE CHILD’S PROOF OF BIRTH • COPY OF THE CHILD’S SOCIAL SECURITY CARD • COPY OF THE CHILD’S IMMUNIZATION RECORD • COPY OF THE CHILD’S PHYSICAL OR WELL-CHILD CHECK-UP

Child Information:

Child's Name(Required)
Today's Date(Required)
Gender
Child's Birthday(Required)
Parental Status:(Required)
HAS THIS CHILD ATTENDED A STATE-FUNDED PREK PROGRAM BEFORE?(Required)
IS THIS CHILD ENROLLED IN HIPPY OR PAT PROGRAM?(Required)
IS THIS CHILD RECEIVING OR BEEN REFERRED FOR SPECIAL SERVICES?(Required)

Child's Demographic Information:

Speak English at Home?
English Skills
Child's Ethnicity
Hispanic
Child's Race
DOES THE CHILD HAVE ANY ALLERGIES OR MEDICAL ALERTS?
*MUST PROVIDE A COPY INCLUDING HEARING & VISION SCREEN (must be within the last year).
IS THE CHILD UP TO DATE ON IMMUNIZATIONS?(Required)
*MUST PROVIDE CURRENT IMMUNIZATION RECORD
AUTHORIZATION TO DISCLOSE IMMUNIZATION RECORDS: I AUTHORIZE THE ARKANSAS DEPARTMENT OF HEALTH TO DISCLOSE IMMUNIZATION RECORDS TO LINCOLN CHILDCARE CENTER, INC. FOR THE CHILD LISTED ON THIS APPLICATION. I UNDERSTAND THAT THIS AUTHORIZATION WILL EXPIRE UPON DISCHARGE OF MY CHILD.
DOES THE CHILD HAVE MEDICAL INSURANCE?
SPECIFY:
EMERGENCY CONSENT AUTHORIZATION: I DO HEREBY REQUEST AND GIVE CONSENT TO THE DIRECTOR OF LINCOLN CHILDCARE CENTER, INC. OR THE DULY APPOINTED REPRESENTATIVE FOR THE CHILD LISTED ON THIS APPLICATION TO RECEIVE SUCH MEDICAL OR SURGICAL AID AS MAY BE DEEMED NECESSARY AND EXPEDIENT BY A DULY LICENSED OR RECOGNIZED PHYSICAN OR SURGEON IN CASE OF AN EMERGENCY WHEN I, THE PARENT OR CAREGIVER, CANNOT BE REACHED. CONSENT IS ALSO GIVEN FOR THE DIRECTOR, OR DULY APPOINTED REPRESENTATIVE TO TRANSPORT SAID CHILD FOR EMERGENCY MEDICAL TREATMENT.

Authorized Pick-Ups / Emergency Contacts

*ONLY PERSONS LISTED ON THIS FORM WILL BE ALLOWED TO PICK THE CHILD UP. PHOTO ID’S WILL BE REQUIRED. AUTHORIZED PICK-UPS MUST BE AT LEAST 18 YEARS OF AGE.
Child's Name
DOES MOTHER LIVE IN THE HOME OF THE CHILD?
DOES FATHER LIVE IN THE HOME OF THE CHILD?
Mother's Address
Father's Address
Mother's Work/School Days
Father's Work/School Days
IS THERE A COURT ORDER PREVENTING EITHER OF THE ABOVE FROM PICKING UP THE CHILD?
*COPY OF COURT ORDER MUST BE PROVIDED.

Section Break

PERSON TO CONTACT WHEN PARENTS CANNOT BE REACHED:
EMERGENCY CONTACT

OTHER PERSONS BESIDES THOSE LISTED ABOVE WHO CAN PICK THE CHILD UP

Pick-Up 1 Name
Pick-Up 2 Name
Pick-Up 3 Name
Pick-Up 4 Name

GENERAL INFORMATION ABOUT THE CHILD:

DOES YOUR CHILD HAVE ANY SIBLINGS?
IS YOUR CHILD POTTY TRAINED?
IF NOT FULLY POTTY TRAINED, DOES YOUR CHILD WEAR UNDERWEAR OR PULL-UPS?
This field is for validation purposes and should be left unchanged.