Preschool Scholarship Program - tri-town youth services

Applicant Name

First

Last

DOB

Primary Language

Parent/Gurdian Name

First

Last

Street Address

Town/Zip Code

First

Last

Phone/Email

First

Last

Names/Ages of other children

Has your child ever attended preschool?

Yes
No

If yes, where and for how long?

Do you have transportation to bring your child to and from preschool?

Yes
No

Preschool Preference: (list top 2 choices)

First

Last

Yearly Family Income:

Is there any other information you would like the Scholarship Committee to know about your family situation?

By signing the space below, you are acknowledging that you have read and agree to the above guidelines and certify that all information provided in the application is accurate.

Parent/Gurdian Signature, Date