Royalton-Hartland Central School District

Universal Pre-Kindergarten Program Application 2009/10
 (Contingent upon the availability of New York State Universal Pre-K funds)

Child’s Name:  
Parent(s)/Guardian(s)    
Address:      
City:          Zip:       
Home Phone:      Work/Cell Phone:       
Child’s Date of Birth:       Child’s Gender:    * Male Female  

Language Spoken at Home:       

Does your child receive any special education services of have other special needs? 
Please List:       

I would prefer my child attend:   * AM (9:00-11:30am) PM (12:45-3:15pm)

Other children at home:

Name:    School:      
Name:    School:      
Name:    School:      

In case of emergency, please contact:

Name:       Phone:      
Name:        Phone: