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School Readiness Application (online application at https://spe.schoolreadiness.org/pe/)

Please fill out application completely
Parent & Household Information
Primary Parent/Guardian First Name: Last Name: Relationship to child: Parent Step Parent Guardian Race: Black White Asian Hawaiian/Pacific Separated Widowed Hispanic US Indian/Alaskan Sex: Male Female Non- Hispanic Marital Status:Single Married Divorced Date of Birth: Social Security : Are you disabled? Are you a Student? Yes Yes No No Other: Foster Parent Primary Language Spoken: Secondary Parent/Guardian (ONLY IF IN HOUSEHOLD) First Name: Last Name: Relationship to child: Parent Step Parent Guardian Race: Black White Asian Hawaiian/Pacific Separated Widowed Hispanic US Indian/Alaskan Sex: Male Female Non- Hispanic MaritalStatus: Single Married Divorced Date of Birth: Social Security : Are you disabled? Are you a Student? Yes Yes No No Other: Foster Parent

If Yes how many credit hours? Are you employed? Employer Name: Work Phone: Number of hours worked per week? Gross Earnings: Hourly Rate: Salary: Weekly Bi-weekly Monthly Semi-Monthly Yes No

If Yes how many credit hours? Are you employed? Employer Name: WorkPhone: Number of hours worked per week? Gross Earnings: Hourly Rate: Salary: Weekly Bi-weekly Monthly Semi-Monthly Yes No

Does anyone in the house receive: NO Child Support Alimony TANF/AFDC Veteran's Benefits Retirement Social Security Residential Address: Address: City: County: Phone Number: YES Amount

(Please provide monthly amount and name of family member receiving income) Name SSIUnemployment Worker's Comp Interest/Dividends
Relative Care Giver Funds (RCG)

NO

YES

Amount

Name

Other Mailing Address: (If different than Residential Address) Address: Zip Code: City: E-mail: Alternate Number: Zip Code:

Please fill out child(ren)s information on back side of application. Once completed please submit application to your local coalition office listed below:Charlotte Office                            DeSoto Office                                  Hardee Office                                 Highlands Office                                                    3028 Caring Way, Suite 4                  4 West Oak Street, Suite H                  324 N. 6th Avenue             209 N. Ridgewood Drive  Port Charlotte, FL  33952                  Arcadia, FL  34266                               Wauchula, FL   33873             Sebring, FL  33870                                                  Phone:   (941) 255‐1650         Phone:   (863) 494‐5233                        Phone: (863) 767‐1002             Phone:  (863) 314‐9213                Fax:        (941) 255‐5856         Fax:        (863) 494‐5291                        Fax:      (863) 767‐1007            Fax:       (863) 314‐4480   

 

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” Margaret Mead

Revised 08-21-08

PLEASE LIST ALL CHILDREN IN THE HOUSEHOLD

Child(ren) Information:
First Name: Gender: Race: Female Black Male White SS # : Asian US Indian/Alaskan Last Name: Date of Birth: Are ScholarshipServices needed for this child? Hawaiian/Pacific Hispanic Non-Hispanic Yes No

Are there any special needs for this child? If so please explain:

First Name: Gender: Race: Female Black Male White SS # : Asian

Last Name:

Date of Birth: Are Scholarship Services needed for this child? Yes No

US Indian/Alaskan

Hawaiian/Pacific

Hispanic

Non-Hispanic

Are there any special needsfor this child? If so please explain:

First Name: Gender: Race: Female Black Male White SS# : Asian

Last Name:

Date of Birth: Are Scholarship Services needed for this child? Yes No

US Indian/Alaskan

Hawaiian/Pacific

Hispanic

Non-Hispanic

Are there any special needs for this child? If so please explain:

First Name: Gender: Race: Female Black Male White SS # :...
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