This form is only for current year (2022-23). To register for next fall use the 2023-24 form.

Are you looking for placement before 6/15/2023?*

Yes No

Please fill out all required fields below.

Registering your child on this form does not guarantee them a spot in one of the LNSU school based classrooms. You must attend a screening at your local school.

Do not use this form. Use the 2023-24 PreK form found at lnsu.org.

Student Information

Student Legal First Name required

Student Legal Middle Namerequired

Student Legal Last Namerequired

Student DOB:required

Legal Gender*

M F

Expected Enrollment Daterequired (mm/dd/yyyy)

Please upload Birth Certificate

A BIRTH CERTIFICATE IS REQUIRED FOR ALL NEW STUDENTS. FOR NEW STUDENTS, IF YOU CANNOT UPLOAD ONE TODAY, YOU WILL NEED TO DELIVER ONE TO SCHOOL BEFORE YOUR CHILD CAN BEGIN.

Max file size: 10 MB

Race*

Is this student in state custody (DCF, NFI, etc.)?*

Yes No

Please Upload Related State Custody Documents

Max file size: 10 MB

Is there anyone legally forbidden to have access to this student?*

Yes No

Please list by name the person forbidden access.

Please upload legal court document related to this restricted person.

Max file size: 10 MB

Currently in Special Education?*

Yes No

Received SPED services in the past?*

Yes No

Permission is granted for the school to bill Medicaid for my special education student.

Yes No

Currently in 504 services?*

Yes No

Received 504 services in the past?*

Yes No

Previous School Name and Address

If this is the first time your child has been enrolled in school enter "None"

We are requesting that my Pre K child be enrolled in*

A Community Partner Pre-K Program Cambridge Elementary Pre-K Eden Central School Pre-K Hyde Park Elementary Pre-K Johnson Elementary Pre-K Waterville/Belvidere Elementary Pre-K

Act 166: Universal Prekindergarten Tuition Request Form 2022-2023 School Year

Children must be 3, 4, or 5 years of age on or before September 1st. The child may remain enrolled at age 6, however, access to Act 166 Tuition will cease at the child’s birthday. Children enrolled in Act 166 may not also be enrolled in Kindergarten.

Children must be 3, 4, or 5 years of age on or before September 1st. The child may remain enrolled at age 6, however, access to Act 166 Tuition will cease at the child's birthday. Children enrolled in Act 166 may not also be enrolled in Kindergarten. Please note that several other forms are required for a complete application packet.

Barre Unified Union School District	Central Vermont Supervisory Union
Harwood Unified Union School District	Lamoille South Unified Union
Lamoille North Supervisory Union	Montpelier Roxbury School District
Orange Southwest School District	Orleans Southwest Supervisory Union
Washington Central Unified Union School	White River Valley Supervisory Union

We are requesting that my Pre K child be enrolled in the following school/program:

I agree to complete the registration process with my resident school district, which includes proof of residency and proof of age.

This includes proof of residency and proof of age. Schools will provide up to $3,656 per school year to one pre-qualified pre-kindergarten provider if the child’s registration is complete before the start of the school year. I understand that my child’s tuition will be prorated based on the date that I fully complete registration and/or update the information if my child was enrolled last year. (10 hours per week for 35 weeks).

Yes No

I agree to follow the attendance policy provided by the prekindergarten program and ensure that my child attends pre kindergarten consistently.

I understand it is my responsibility to notify the Supervisory Union/Supervisory District if we move or if my child stops attending pre-kindergarten or changes programs.

Yes No

I agree to authorize the release of information between my child's prekindergarten program to communicate with my school district about my child's development, enrollment, attendance, registration and suspension/expulsion.

Yes No

Residency

Physical Address including street, city, state, and zip coderequired

Click Yes for Additional Information

Yes No

The Lamoille Union School Board is responsible for ensuring the education of pupils who are residents in the Lamoille North Supervisory Union School District. This is comprised of the following towns: Belvidere, Cambridge, Eden, Hyde Park, Johnson and Waterville. In addition, the Board has a responsibility to the taxpayers of this District to be sure that the District is only educating those students whose parents, legal guardians or custodians live in this District, or who meet the legal exceptions to the residency requirement. (example: towns such as Wolcott, where the local District does not include middle or high schools, and students may attend middle and high schools in neighboring districts, tuitioned by their home district) State law allows the district to refuse to accept or to dismiss students who are not legal residents of the district.

In order to determine whether a student is a legal resident as defined by Vermont law, the District must require proof of residency for new students as described below. An exception is if you are homeless and live in any of the following situations: in a shelter, motel, vehicle or campground; on the street; in an abandoned building, trailer or other inadequate accommodations, or doubled up with friends or relatives because you cannot find or afford housing. Contact your school principal and ask about the McKinney-Vento Homeless Education Assistance Act.

Parents, legal guardians or custodians of students must provide proof of primary residency in one of our six towns to the school when enrolling a new student for the first time, when re-enrolling after withdrawal, or if a student’s residency is questionable by providing one of the following:

Current tax bill with parent/legal guardian’s name and address (monetary information blacked out)
Current mortgage papers or closing statement showing parent/legal guardian’s name and address
Formal rental agreement showing name, address and telephone number of the landlord and parent/guardian as renter
A notarized letter from the landlord stating the address of the residence being leased and the name(s) of the lessee(s), along with the landlord’s address and telephone number.In some cases where residency is questionable, the District may also require completion and notarization of the “Affidavit Concerning Pupil Residency”.

Provide Proof Residency:

EXCEPT FOR HOMELESSNESS, RESIDENCY DOCUMENTATION IS REQUIRED. IF YOU CANNOT UPLOAD ONE TODAY, YOU WILL NEED TO DELIVER ONE OF THE FOLLOWING DOCUMENTS TO SCHOOL BEFORE YOUR CHILD CAN START ATTENDING. -Current tax bill with parent/legal guardian’s name and address (monetary information blacked out) - Current mortgage papers or closing statement showing parent/legal guardian’s name and address - Formal rental agreement showing name, address and telephone number of the landlord and parent/guardian as renter - A notarized letter from the landlord stating the address of the residence being leased and the name(s) of the lessee(s), along with the landlord’s address and telephone number - If homeless, please contact Jen Hulse at jhulse@lnsd.org.

Max file size: 10 MB

Parent/Contact 1 Information

Parent/Guardian 1 Legal First and Last Name:required

Parent/Guardian 1 Email Addressrequired

Parent/Guardian 1 Home Number:required

Parent/Guardian 1 Mobile Numberrequired

SMS mobile phone?

Yes No

Parent/Guardian 1 Mailing Address (if different from Physical Address)required

How is this Parent/Guardian1 related to the student? (Mother, Father, etc.)required

Parent/Guardian 1 has custody?*

Yes No

Student lives with Parent/Guardian 1*

Yes No

Is there a second parent/legal guardian?*

Yes No

Parent/Guardian 2 Information

Parent/Guardian 2 Legal First and Last Name:

Parent/Guardian 2 Email Address

Parent/Guardian 2 Home Number:

Parent/Guardian 2 Mobile Number

Parent/Guardian 2 Mailing Address (if different from Physical Address)

How is this Parent/Guardian2 related to the student? (Mother, Father, etc.)

Parent/Guardian 2 has custody?

Yes No

Student lives with Parent/Guardian 2

Yes No

Parent/Guardian 2 may pick up from school?

Yes No

Is there an emergency contact in case a parent/guardian listed above cannot be reached?*

Yes No

Emergency Contact 1

Emergency Contact 1 Name

Emergency Contact 1 Phone Number

Does this person have permission to pick your child up from school?

Yes No

Is there a second emergency contact?

Yes No

Emergency Contact 2

Emergency Contact 2 Name

Emergency 2 Contact Number

Does this person have permission to pick up your child from school?

Yes No

Authorized Signature

Your typed name below serves as a signature certifying the accuracy of the above informationrequired

Date required (mm/dd/yyyy)

Please Note:

After this form is submitted, you will receive an immediate automated acknowledgement. It will then be handled by our Director of Early Childhood Education, Melinda Mascolino.

Please send a confirmation email to the address below:

Please provide an email address where we can send a link to your current form.

Email Address :