This form must be completed by a parent, guardian, or other individual having lawful control over the child.
Relationship to Child:
Date of Birth:
Apartment or Unit Number:
Pre-K is a qualifying program. Please answer the questions in the following sections to help us determine your child's eligibility.
Does the child live in any of the following situations? Check all that apply.
Owner-occupied home (own or lease home, apt., etc.)
Long-term agreed-upon living arrangement with a family member or friend
Emergency shelter or transitional housing
Hotel or Motel
Non-traditional housing space including cars, public spaces, or substandard housing
Foster care placement for six (6) months or less
Shared housing with friend, family, or others due to hardship
Does the child live with the parent or legal guardian?
Has the child ever been placed in Texas Department of Family and Protective Services kinship care, volunteer care, or foster care?
Is the child a dependent of a member of one of the following?
Not a military dependent
Active member of Armed or Reserved Forces of the United States or Member who has been injured or killed while on active duty or Member who is currently listed as Missing In Action
Texas National Guard
Star of Texas Award
The Star of Texas Award honors peace officers, firefighters, and emergency medical first responders who were seriously injured or killed in the line of duty.
Is the child a dependent of a "Star of Texas Award" nominee?
What language is spoken in your home most of the time?
What language does your child speak most of the time?
Do you receive SNAP benefits?
Do you receive TANF benefits?
Do you receive Medicaid benefits?
Do you receive CHIP benefits?
Number of residents in household:
Number of incomes in household:
ALL OF THE INFORMATION SUBMITTED IS CORRECT
I understand that Texas Penal Code Section 37.10 states that it is an offense to (1) make a false entry, or false alteration of a government record, (2) present a document with knowledge of its falsity, or (3) impair the verity or legality of the record.
I further understand that the Texas Education Code, Section 25.001(h), states that it is an offense to knowingly provide false information on a form required for enrollment of a student.
Offenses may result in legal actions including, but not limited to, fines and/or liability for payment of tuition.
I understand that by checking the checkbox next to "Yes, I agree" below constitutes a legal signature confirming that I acknowledge and agree to the above statement.
Yes, I agree (required)
Electronic Signature (Please type your first and last name)