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Carlisle

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HAC

Parents
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HAC

Carlisle

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Pre-K
Carlisle Pre-K Application

Carlisle Pre-K Application

Enrollment Form

Carlisle Pre-K Application

Primary Caregiver Information

(Parent or guardian with the most contact with the child.)

Reaquired field: Name (First/Middle/Last
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Reaquired field: Date of birth
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Reaquired field: Home Phone
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Reaquired field: Work Phone
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Reaquired field: Current Address
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Reaquired field: Apt. #
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Reaquired field: City, State
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Reaquired field: Zip Code
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Employment Status

Reaquired field: FT

Reaquired field: PT

Reaquired field: Unemployed

Reaquired field: Other

Other

Reaquired field: Employer Name
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Reaquired field: Employer address
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Reaquired field: Employer City,State / Zipcode
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Reaquired field: Number of hours a week
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Reaquired field: Annual income from work sources or unemployment
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Reaquired field: Education level
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Reaquired field: If attending school, where? How many semester hours?
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Secondary Caregiver Information

(2nd Parent or Caregiver in the household with the child. Used for determining eligibility.)

Reaquired field: Name (first/middle/last)
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Reaquired field: Date of Birth
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Reaquired field: Home Phone
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Reaquired field: Work Phone
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Current Address

Reaquired field: Same as primary caregiver

Reaquired field: City, State / Zipcode
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Employment Status

Reaquired field: FT

Reaquired field: PT

Reaquired field: Unemployed

Reaquired field: Employer Name
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Reaquired field: Employer address
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Reaquired field: Employer City, State / Zipcode
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Reaquired field: Number of hours per week
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Reaquired field: If attending school, where?
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Reaquired field: Number of semester hours
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Reaquired field: Annual income from work sources or unemployment
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Household Information

Reaquired field: Number in family living in the home (parents, guardian, siblings)
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Reaquired field: Number in household (the total number of all people living in the house.)
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Reaquired field: List the names and relationship (to the child enrolled) of all family members living in the home
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Child Information

Reaquired field: Name (first/middle/last)
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Reaquired field: Date of birth
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Reaquired field: Child's Social Security Number
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Gender

Reaquired field: Male

Reaquired field: Female

Reaquired field: Ethnicity
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Reaquired field: Primary language
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Has the child attended a state funded Pre-K (ABC) program before?

Reaquired field: Yes

Reaquired field: No

Reaquired field: If so, where?
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Will the child be concurrently enrolled in an ABC center and HIPPY or PAT program?

Reaquired field: Yes

Reaquired field: No

Reaquired field: If so, which HIPPY or PAT?
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Reaquired field: List all allergies
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Reaquired field: Does the child have any special dietary needs?
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Reaquired field: Does the child receive any special education services?
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Emergency Contact and Consent Information

Reaquired field: Name of emergency contact if parent or guardian cannot be reached and their relationship to the child
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Reaquired field: Phone number of emergency contact person
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Reaquired field: Address
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Reaquired field: City, State / Zipcode
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Reaquired field: Physician Name
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Reaquired field: Physician address
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Reaquired field: Physican City, State / Zipcode
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Consent for emergency medical care (please initial)
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Reaquired field:

Reaquired field: Signature
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Reaquired field:

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Required Fields

Carlisle Public Schools

520 Center St, Carlisle, AR 72024
Phone: 870.552.3931

Administrative Office 870-552-3931
Elementary School 870-552-3261
High School 870-552-3196

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Carlisle Public Schools

520 Center St, Carlisle, AR 72024
Phone: 870.552.3931

Log In

Administrative Office 870-552-3931
Elementary School 870-552-3261
High School 870-552-3196

Log In

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