LAKE LOCAL SCHOOLS 2016-‐2017 Pre-‐Registration Information
Thank you for your interest in the Lake Preschool. A number of changes to the preschool program have been made to meet the Ohio Department of Education’s requirements for the 2016-‐2017 school year. The Lake Preschool is located at Lake Middle School. Our preschool is a play-‐based, developmentally-‐ appropriate preschool serving children with and without special needs. Children with identified delays in development are placed into the preschool after an extensive assessment process and once they reach their 3rd birthday. In order to attend under the income based preschool grant a typically developed child must be 4 years old by August 1st . Full pay, typically developing 3 year olds may also be accepted to the program. Preschoolers attend five (5) half-‐days per week during either a morning or an afternoon session. All typically developing children must be fully toilet trained. Bussing service is NOT available. Location Information: Lake Middle School 28100 Lemoyne Rd Millbury, OH 43447 AM Session 8:45 – 11:30 PM Session 12:45 – 3:30 Children currently attending Lake’s preschool have first opportunity to return the following year. Children on the current year’s preschool waiting list must pre-‐register again for the following school year. Placements for non-‐special needs children are first-‐come, first-‐served based on the vacancy available. Placements include factors such as income level, with preference given to underprivileged children.
Pre-‐Registration Procedures Complete the pre-‐registration forms along with the Interest/History forms. You then can either drop off or mail the forms along with your proof of residency to: Enrollment Coordinator, Lake High School, 28080 Lemoyne Rd., Millbury, OH 43447. When we receive your pre-‐registration form and proof of residency, you will be contacted by email, phone or letter to confirm your paperwork was received. If you do not receive confirmation, it means we have not received your paperwork. If residency is NOT attached, the application will not be considered complete and will be returned to the parent. You will be notified by letter as soon as possible regarding your child’s status. (If you do not return the pre-‐ registration form to us, we will assume you are no longer interested in our preschool.) All typically developing children new to the program, regardless of their income level, pay a non-‐refundable $10.00 Registration Fee upon acceptance into the program (please do NOT send fee now).
Tuition Information for Children without Developmental Delays Tuition is not charged for children with identified special needs. A tuition of $132.00* per month (tuition is subject to change) will be charged for typically developing children. Cost of the preschool is income based with rates based on the 2016 Federal Family Income Guidelines. Families who qualify to pay less than the full tuition amount must provide proof of income with the pre-‐registration forms. The Sliding Fee Schedule is included with this information. Vacation, calamity and conference days have been taken into account and there will be no refund for absences of that nature. Excess calamity days will be made up. *It may be necessary to make modifications in programming or tuition rates because of uncertainty of local school district funding. There is a possibility that the Ohio Department of Education may cut funding for public preschool. At this time, it hasn’t been determined if, or how much of a reduction will happen. If the funding is cut significantly, tuition may have to be increased for the coming school year. NOTE: The Ohio Department of Education funds Lake’s Preschool Programs specifically for children with developmental delays. In the rare instance that there are no more openings for special needs preschoolers, the state department mandates that the special needs child may have to replace a child with typical development.
Office Use Only: Rec’d ____________ Placed: AM PM Waiting List # ____
Lake School District Preschool Program 2016-‐2017 School Year Pre-‐Registration Form for Typically Developing Preschoolers
Child Name:___________________________________________________________________________
Last
First
Middle
Birth Date: ___________
Social Security #: ____________________ Gender: __________________
Address:
_______________________________________________ _______________________________________________
Home Phone: ___________________________
Child’s City of Birth: __________________________
Session Preference: _____AM
_____PM
_____No Preference
Child lives with: _____ Mother _____ Father _____Both _____Guardian
LEGAL CUSTODIAL FATHER/GUARDIAN Name: __________________________ Address: __________________________ Home Phone: ( ) ______________________ Cell Phone: ( ) ______________________ Employer: __________________________ Business Phone: ( ) ___________________
LEGAL CUSTODIAL MOTHER/GUARDIAN Name: _____________________________ Address: _____________________________ Home Phone: ( ) ________________________ Cell Phone: ( ) ________________________ Employer: ____________________________ Business Phone: ( ) _____________________
The Lake School District requires that every student MUST provide proof of residency. If proof of residency is not attached to the pre-‐registration forms, it will not be accepted and will be returned to the parent.
Please attach either a current utility bill (gas, electric, water) or current lease.
If you are unable to provide either types of proof of residency because you do not own/rent the Lake residence where you are living, you may complete the attached residency verification form and documentation required with this form. The residency verification form must be notarized.
_________________________________________________ ________________________ Parent Signature Date Return Forms to: Lake Local Schools -‐ Preschool Enrollment Lake High School 28080 Lemoyne Rd. Millbury, OH 43447 Page 1 of 6
Please complete this checklist and return along with your proof of income to be eligible for reduced tuition: 1. Number of members in your household: _______ 2. Circle your total income below according to the number of members in your household. 3. If you qualify to pay a reduced tuition rate, please write your yearly gross family income below: Gross family income: ____________________ 4. If your child is accepted into the preschool, proof of income will be required (your last 4 check stub(s)). If proof of income is not provided, the full tuition will be charged. You will be required to notify the school of any change in income.
If proof of income is not provided, typically developing children will be billed $132.00/month
Number In Family
Sliding Fee Schedule -‐ Based on 2016 Federal Family Income Guidelines Total Gross Family Income (BEFORE Deductions)
<100% | 101-‐125% | 126-‐150%
| 151-‐175%
| 176-‐185%
| 186-‐200%
| >200%
2
16,020| 16,021 – 20,025 | 20,026 – 24,030| 24,031 – 28,035| 28,036 – 29,588| 29,589 – 32,040 | 32,041
3
20,160 | 20,161 – 25,200 | 25,201 -‐ 30,240 | 30,241 -‐ 35,280 | 35,281 -‐ 37,233 | 37,234 -‐ 40,320 | 40,321
4
24,300 |24,301 -‐ 30,375 | 30,376 -‐ 36,450 | 36,451 -‐ 42,525 |42,526 -‐ 44,879 | 44,880 -‐ 48,600 | 48,601
5
28,440 |28,441 -‐ 35,550 | 35,551 -‐ 42,660 | 42,661 -‐ 49,770| 49,771 -‐ 52,526 | 52,527 -‐ 56,880 | 56,881
6
32,580 | 32,581 -‐ 40,725 | 40,726 -‐ 48,870 | 48,871 -‐ 56,015 | 56,016 – 60,172 | 60,173 -‐ 65,160 | 65,161
7
36,370 | 36.371 -‐ 45,913 | 45,914 -‐ 55,095 | 55,096 -‐ 64,278 |64,279 -‐ 67,951 | 67,952 -‐ 73,460 | 73,461
8
40,890 | 40,891 -‐ 51,113 | 51,114 -‐ 61,335 | 61,336 -‐ 71,558 | 71,559 -‐ 75,647 | 75,648 -‐ 81,780 | 81,781
Preschool Tuition Rates (Rates may be subject to change) Monthly |0 | $ 22.00 | $ 41.00 | $ 66.00 Yearly
|0 |$ 198.00
| $ 71.00
| $ 110.00 | $ 132.00
| $ 369.00 | $ 594.00 | $ 639.00 | $ 990.00 |$ 1,188.00
Page 2 of 6
LAKE LOCAL SCHOOLS PRESCHOOL – Interest/History Info Child’s Name: ________________________________
Birth Date: ___________
Gender: ___M ___F
Has your child attended preschool/day care? Y N If Yes how long? ___________ Current/Last place attended: _______________________________________
Child’s Interests Preschoolers learn best when they have had first-‐hand experiences and when they are highly interested. In order to maximize their learning at the preschool age, teachers construct learning activities based on the children’s experiences and interests. Please assist us in helping to create the best learning environment for your preschooler by identifying some of their experiences and interests.
Goals for your preschooler: _____________________________________________________________________
What are your child’s favorite activities: ___________________________________________________________
How does your child spend most of his time: _______________________________________________________
Favorite television programs: ___________________________________________________________________
Experiences that have been meaningful (vacation, family event, moving, etc.): ____________________________
______________________________________________________________________________________________________
Celebrated holidays: __________________________________________________________________________
Special customs, traditions, foods: _______________________________________________________________
List topics of interest to your child (e.g. policeman, fireman, animals, nursery rhymes, food, transportation): ______________________________________________________________________________________________________
Child Development: Medical History
Birth Weight: _________ Type of Delivery: Full Term Premature ( ___weeks) Over Due (___weeks) Forceps Delivery complications ______________________________________________________________________
Nutrition ___Y ___N Special diet____________________________________________________________ ___Y ___N Trouble chewing/swallowing______________________________________________ ___Y ___N Food allergies___________________________________________________________ ___Y ___N Eat non food items_______________________________________________________ ___Y ___N Nutritional/eating habit concerns___________________________________________ ___Y ___N Take vitamins___________________________________________________________ ___Y ___N Weight problem_________________________________________________________ Foods your child likes__________________________________________________________________ Foods your child dislikes________________________________________________________________ How much water does your child drink in one day___________________________________________ How many times a day does your child drink milk____________________________________________
Page 3 of 6
Medical/Development
Do you have any concerns regarding your child’s development in any of the following areas, if so please explain: ___Y ___N Vision concerns (crossed eyes) ____________________________________________ ___Y ___N Hearing concerns_______________________________________________________ ___Y ___N Language concerns_____________________________________________________ ___Y ___N Socialization concerns___________________________________________________ ___Y ___N Frequent ear infections__________________________________________________ ___Y ___N Any medical diagnosis___________________________________________________ ___Y ___N Mobility concerns______________________________________________________ ___Y ___N Significant injuries______________________________________________________ ___Y ___N Hospitalizations________________________________________________________ ___Y ___N Other health concerns___________________________________________________ ___Y ___N Have had chicken pox____________________________________________________
Has your child received any therapeutic services (e.g. speech/language, counseling, occupational therapy)? ___Y ___N If Yes, please list type of services, length of services and by who (please provide copy of report if available). ______________________________________________________________________________________ ______________________________________________________________________________________ Please check all which may apply o o o o o o
Very quiet Bites nails Wets bed Often afraid Short attention span Affectionate
o o o o o
Irritable Highly active Sucks thumb Difficult to parent Difficulty playing with others
Destructive Temper tantrums Toileting accidents Sleeping problems Separation anxiety
o o o o o
Please explain further any checked items_______________________________________________________ ___________________________________________________________________________________________ Can your child ___Y ___N feeds self using a spoon and/or fork ___Y ___N dresses with little or no assistance ___Y ___N when speaking can be understood by others ___Y ___N washes/dries own hands ___Y ___N independent toileting ___Y ___N expresses thoughts/needs easily ___Y ___N able to be left with a sitter
Page 4 of 6
Does your child ___Y ___N ___Y ___N ___Y ___N ___Y ___N ___Y ___N ___Y ___N ___Y ___N ___Y ___N
plays with blocks/boxes/construction toys without help uses crayons/markers to scribble or draw listens to stories being read turns/views pages of a book recalls stories or events communicates with friends/relatives when visiting enjoys playing alone or with imaginary friends follows simple, age-‐appropriate directions
Do you have any concerns about your child’s development_____________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________
Anything else you wish to share with us regarding your child____________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________
Parent Signature ________________________________________
Date _______________________
Page 5 of 6
Child’s Name ___________________________________________
Page 6 of 6
Place an X that best describes how your child can do each task:
Always or Most of the Time
Sometimes or Partially
Never or Almost Never
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Waits to hear the entire question before answering
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Blows and wipes nose
Smiles, giggles or laughs in response to humor Describes feelings verbally
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Likes to be with other people Reacts predictably Admits mistakes Doesn’t blame others Asks permission to use others belongings Plays well with others
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Focuses on activity for minimum of 15 min
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Uses words to settle arguments with other children
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Respectful of toys Waits his/her turn when playing games
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Is well liked by other children
Listens and follows parental directions Accepts limits without frustrations Completes tasks required
This form should be completed if you cannot prove residency in the Lake Local School District with a utility bill or lease agreement.
LAKE LOCAL SCHOOLS - RESIDENCY VERIFICATION According to Ohio’s School Attendance Law (O.R.C. 3313.63) a school age student can only attend school tuition-free* in the district where his/her biological/custodial parent resides. This form must be completed, signed by both Parent and Residence Owner/Renter and notarized, whenever a parent cannot verify that he/she owns or rents a residence in the District. *Preschoolers pay tuition based upon a
sliding scale. Please return this completed form along with proof of residency (current utility bill/lease) from the Lake Resident. SECTION I: (to be completed by the legal parent/guardian) Student’s Name: ____________________________________School: _________________ Parent’s Name: ________________________________________________
Although I do not own or rent a residence in the Lake District, this is to certify that I am the custodial parent/guardian of the child named above and our current permanent residence (residence - where the parent/guardian and student(s) in question eat their meals and sleep on a regular basis, receive their mail, and if applicable where the parent(s) are registered to vote) is:
Residence: __________________________________________________________________ (Street)
(City)
(Zip)
Should I change this, my permanent residence, I understand that my child may no longer be eligible to attend school in Lake Local Schools. I promise to notify the school immediately if my residence changes. I also understand that if in fact the stated information is not true, and in fact my child does not meet the residency requirements as defined by the State of Ohio, I will be responsible for paying tuition from the date of enrollment.
_______________________________________________
___________
Parent Signature
Date
SECTION II: (to be completed by the Lake Resident with whom the family is living)
Living at the address listed above as Guests of:
Name: ________________________________________________________
Telephone: __________________
______ Own
______ Rent
According to Ohio Tuition Law, the resident of the school district who permits a non-resident student to reside with them can be held responsible for paying all tuition due, during the time the student resides in their home. It is understood that fraudulent reporting of residency for school attendance purposes is a violation of state law and could result in prosecution of all related parties, in a court of law. Further, as the resident of the Lake Local School district, I understand I can be held personally liable for any and all tuition obligations for all days of fraudulent attendance left unpaid by the custodial/biological parent.
_______________________________________________
___________
Signature of Residence Owner/Renter
Date
SECTION III: (to be completed by the Notary Public) SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE THIS ____________ DAY OF
___________________20_____. (Seal)
__________________________________ NOTARY PUBLIC, STATE OF OHIO
_________________ COMMISION EXPIRES
NOTICE: READ CAREFULLY: Knowingly falsifying this document is a violation of the Ohio Revised Code: Section 2921.13 (A) (6) which is a First Degree Misdemeanor punishable by a prison term of six (6) months and/or a fine up to $1,000.00. Further, the student’s residential parent will be billed (and prosecuted in court, if necessary) to collect all back tuition which may be due. Inaccurate and/or false information will result in immediate withdrawal of your child(ren) from Lake Local School District. 2 Proof of Residency (Driver’s License & 1 piece of US stamped mail) for the residential parent/guardian will then be required within 30 days of registration.
