Parent(s)/Guardian Name: Number in Household:

Address: City Zip:

E-mail:

Applicant Information:

Student’s Name: Birth Date: << Choose One >> 2 Day Program 3 Day Program 5 Day Program
Student’s Name: Birth Date: << Choose One >> 2 Day Program 3 Day Program 5 Day Program
Student’s Name: Birth Date: << Choose One >> 2 Day Program 3 Day Program 5 Day Program


Check Preschool Applying For:

Central Preschool
Washington Elementary School
The Learning Center - New Hampton
Nora Springs Community Schools
Fun in the Son Preschool
Merri-land Preschool
Rainbow Preschool
Growing Tree Preschool
Nashua Plainfield
RRMR Preschool
Immaculate Conception Preschool
Nashua Plainfield: Plainfield
St. John Christian Preschool
Kids Care Preschool
Noah’s Ark Preschool
St. Joseph Sunrise Preschool
The Learning Center - Charles City
Other

Fill out part A, B, or C; verify part D

Part A

If you are a recipient of one of the following, check:

Medicaid
Food Stamps
Free School Meals
Reduced School Meals
SSI
FIP (Family Investment Program)
Other (list)

Part B - Complete the following ONLY if you are not currently enrolled in one of the above programs; include each household member.

Person 1
Name, first and last Age
Gross amount of paychecks How often received << Choose One >> Daily Weekly Every other week Monthly Yearly
Amount of other payments received* How often received << Choose One >> Daily Weekly Every other week Monthly Yearly

Person 2
Name, first and last Age
Gross amount of paychecks How often received << Choose One >> Daily Weekly Every other week Monthly Yearly
Amount of other payments received* How often received << Choose One >> Daily Weekly Every other week Monthly Yearly

Person 3
Name, first and last Age
Gross amount of paychecks How often received << Choose One >> Daily Weekly Every other week Monthly Yearly
Amount of other payments received* How often received << Choose One >> Daily Weekly Every other week Monthly Yearly
(*Including social security, unemployment benefits, veteran’s benefits, child support, alimony workman’s comp., other.)

Part C:

Optional Income Verification:

Copies of the following documents may be sent to the preschool you choose above.
Please check if you will be sending any of these documents

Income Tax Return 1040 A or 1040
W-2 Form
Number in Household

Part D:

I certify that all of the above information is correct and that all income is reported. I understand this information is being given in receipt of state funds. FMC Empowerment officials may verify the information on the application. Deliberate misrepresentation of this information will terminate eligibility for funds and I will be responsible for reimbursement of any funds already received. All information contained here will be kept confidential and used for FMC Empowerment purposes only. Please check the box that you understand the statement above

Parent / Guardian completing form: