2020-2021
MANSFIELD SCHOOL READINESS
PROGRAM APPLICATION
Child’s Full Name: _________________________DOB: ____________________Gender: ______
Home Address:__________________________________________________________________
Parent/Guardian: __________________________ Parent/Guardian: _____________________________
EMAIL: _________________________________ EMAIL: _____________________________________
Home Address: ___________________________ Home Address: ______________________________
Phone (h): _______________________________ Phone (h): __________________________________
Phone (c): ______________________________ Phone (c): __________________________________
Total Household yearly income (verification required) $____________________
Form of Verification (Check one): Tax Return/W-2 Letter of Employment Gov’t Subsidy
Marital Status (Check one): Single Married Separated Divorced
The Child Resides with: ___________________ Family Size (Related to this income) _______
Health Insurance Type (Check one): Public Private
Do any children in the immediate family currently attend a program? If yes, where:_______________
Center requested: Community Children’s Center Mansfield Discovery Depot UConn Child Labs
Type of space: Full-time Part-time
I understand that, as a parent participant in the Mansfield School Readiness Program, I am
required to submit to the School Readiness Coordinator written documentation of the gross
income of my family.
I understand that I must notify the School Readiness Coordinator as soon as I am aware of a
change in the gross income of my family.
I understand that, as a parent participant in the Mansfield School Readiness Program, I give my
permission for my child’s enrollment information to be submitted to the OEC’s confidential
Early Childhood Information System (ECIS).
_____________________________________ _________________________________
Signature of Parent(s)/Guardian(s) Date
Questions? Call 860.429.3338
Return completed form to:
Early Childhood Services Coordinator
4 S. Eagleville Rd, Room 25, Mansfield, CT 06268
Or scan and email to: dufresnes@mansfieldct.org
For office use
Slot Type: ____________
Center: ______________
Weekly Fee: __________
