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Raising Riley
Contact Us
Camp Kindergarten 2023 Application
Child's First and Last Name
Address
Has your child attended preschool?
Yes
No
Birthday
Phone
Does yor child have a development delay, disability or health concern?
Yes
No
Does your child have and IEP (Individual Education Plan)? If Yes a copy of the IEP and case manager contact information is required.
Yes
No
Child's Gender
Male
Female
Child's Ethnicity:
Hispanic/Latino/Spanish Origin
Non-Hispanic
Child's Race:
American Indian
Asian
African American or Black
Native Hawaiian or Pacific Islander
White
Does your child speak a language other than English at home?
Yes
No
Child's Primary Language
Child's Health Insurance
Medicaid
Private or Other
No insurance
Camp Kindergarten Session Preference
Morning 8:30 am - 11:30 am
Afternoon 12:30 pm - 3:30 pm
Does your child require transportation in order to attend Camp Kindgerten?
Yes
No
If yes, please provide address for pickup and drop off:
Parent/Guardian Name
Address
Phone
E-Mail Address
Parent/Guardian Date of Birth
Relationship to Child
Parent/Guardian Gender
Marital Status
Parent's Ethnicity:
Hispanic/Latino/Spanish Origin
Non-Hispanic
Does parent speak a language other than English at home?
Yes
No
Parent's Primary Language
Parent's Race:
American Indian
Asian
African American or Black
Native Hawaiian or Pacific Islander
White
Parent's Health Insurance
Private or Other
Tri-Care
None
Number of Adults in Household
Number of children under 18 (include recipient) in household
Income Informaton
Less than $10,000
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $89,999
$90,000 - $99,999
Greater than $100,000
Upload Individual Educaton Plan (IEP)
Upload supported file (Max 15MB)
Housing Arrangements
Stable Housing
Temporary Housing
Homeless/living in a shelter
Upload Case Manager Contact Information
Upload supported file (Max 15MB)
Apply Now >
Thanks for submitting!
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