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The School District of Lancaster K3/K4 Application

This information is confidential

First Name (child)	Middle Initial (child)	Last Name (child)
Birth Date (child)	Household (Family) Size	Parent Name
Address Line 1
Address Line 2
City	State	Zip Code
County	Home Phone	Work Phone
Email Address

Household Income -

Parents will be asked to provide income verification in the form of a W-2 or paycheck stub. Approved forms of income verification must be current and dated within the last 12 months.

I would be able to take my child to one of the following schools for K3 or K4:	1st Choice
	2nd Choice

Are you receiving welfare or food stamps?
Do you have 3 or more children under the age of 5?
Was the program recommended to you by a doctor or caseworker?
Does your family have difficulty with housing or are living in a shelter?
Does anyone in your family have any health concerns?(Examples: nutrition, drugs, alcohol and/or mental health issues)?
Are any of the child’s parents in prison?
Does your child receive special education services from IU13 or an Early Intervention Program?
Is the child a foster child, a kinship care child or receiving services from Children and Youth?
Did the child’s mom and/or dad not graduate from high school or receive a GED?
Were you under the age of 18 when the child was born?
What is the primary language spoken at home?

Please Note: This is a preliminary application and if your child is selected you will need to complete the enrollment process and provide: birth certificate, immunization records, and proof of address (lease, mortgage, or utility bill).

To the best of my knowledge, the information provided is accurate. I understand that I may be asked to verify or substantiate information provided.