Pre-Kindergarten and Kindergarten Registration

Buckholts ISD Pre-Kindergarten Pre-Qualification Application/Kindergarten Registration To be eligible for the Pre-K program, your child must be 4 years of age as of September 1 of the current school year AND must meet one of the requirements below.

Enrollment Form

Student First Name*

Student Middle Name*

Student Last Name*

Student Date of Birth*

Parent/Guardian First Name*

Parent/Guardian Last Name*

Parent/Guardian Email Address*

Additional Parent/Guardian First Name

Additional Parent/Guardian Last Name

Additional Parent/Guardian Email Address

Street/Mailing Address*

Address*

City*

State*

Zip Code*

Country*

Home/Cell Phone Number*

Home Language Survey

An oral language proficiency test is required. An appointment will be scheduled if the answer to the questions below is other than English.

What language does your child speak most of the time?

What language is spoken in your home most of the time?

Foster Care Questions

If the answer to the question below is "Yes",State Conservator Court Order or Letter of Pre-K Eligibility from TX Dept of Family and Protective Services is required.

Has this child ever been in foster care?

Yes No

If the child is a foster child, please list the child's monthly personal use income. Type "O" if the child has no personal use income.

Students Current Living Conditions

Please Choose the option below that best describes where the student is presently living.*

In my own home or apartment with parent or guardian.

Reaquired field: In my own home or apartment, in Section 8 housing, or in military housing with parent(s), guardian(s), or caregiver(s)

In the home of a friend or relative because I lost my housing (examples: fire, flood, lost job, divorce, domestic violence, kicked out by parents, parent in military and was shipped out, parent(s) in jail, etc)

In a shelter because I do not have a permanent housing (examples: living in a family shelter, domestic violence shelter, children/youth shelter, FEMA housing)

In transitional housing (housing that is available for a specific length of time only and is partly or completely paid for by a church, a nonprofit organization, or another organization)

Reaquired field: In a hotel or motel (examples: because of economic hardship, eviction cannot get deposits for permanent home, flood fire, hurricane, etc.)

In a tent, car, van, abandoned building, on the streets, at a campground, in the park, or other unsheltered location.

Does Your Home Have Running Water?

Does your home have electricity?

Yes No

Military Dependents

Is your child a military dependent?*

Yes No

Household Members and Income Information

Please complete all of the information below for each member of your household.

Household Member #1 First Name*

Household Member #1 Last Name*

Household Member #1 Age*

Household Member #1 Gross Income*

Household Member #1 Gross Income-Job #2

Household Member #1 Montlhy Welfare Payments, Child Support, Alimony Income*

Household Member #1- Monthly Pension Payments, Retirement, Social Security Income*

Household Member #1- Monthly-All other income*

Are there any additional individuals living in the household?

Yes No

If you answered "No" to the question above please skip to EDG & SNAP Information

Household Member #2 First Name

Household Member #2 Last Name

Household Member #2 Age

Household Member #2 Gross Monthly Income

Household Member #2 Gross Monthly Income - Job #2

Household Member #2- Monthly Welfare Payments, Child Support, Alimony Income

Household Member #2- Monthly Pension Payments, Retirement, Social Security Income

Household Member #2- Monthly-All other income

EDG & SNAP Information

EDG Number

SNAP/TANF Case Number

Please sign below by typing your name in the signature box to indicate that you have read and understand the procedures for the application and admission into the Buckholts Independent School District.

I understand that a person commits an offense if he/she makes, presents, or uses any record, document or device with knowledge of its falsity and with the intent that it be taken as a genuine record. In addition to the penalty provided by Section 37.10 (Penal Code), a person who knowingly falsifies records is subject to the maximum tuition the district may charge or the amount the district has budgeted for each student. (Texas Education Code, Section 25.00)

Signature of Parent/Guardian*

Today's Date*

Security Measure

BuckholtsISD

Pre-Kindergarten and Kindergarten Registration