Application for Preschool Scholarship
Child's Name:
Date of Birth:
Parent's Name: Address:
Phone:
Total number of dependents claimed on your income tax:
Do you have any concerns about your child?
Is your child currently in a preschool program?
If yes, please check areas of concern:
Physical/Mental Social/Emotional
Language Behavioral
Total number of dependents claimed on your income tax:
Please specify any other areas of concern:
If yes, which preschool program:
When complete, please send this application with a copy of you last income tax to:
Sharon Harvey, Co-Chairperson
Scholarship Committee
70 West River Street
Milford, CT 06460
Sharon may be reached at 203-783-3493