Panama-Buena Vista Union School District

Pre-Kindergarten Application
For Office Use Only:​ PBVUSD Rank #: Family Identification #:

Name of Child: Preference: Preference: 

​◻​ Miller ​◻​ Seibert ​◻​ AM ​◻​ PM 

Foster Family: English Proficient: Primary Language: Number in Family: Number in Household: Application Date:

​◻​ Yes ​◻​ No ​◻​ Yes ​◻​ No 

Parent/Caretaker Information
Complete B if second parent is in the home
Marital Status: ​ ​ Single
◻ ​◻​ Married​ ​◻​ ​ Divorced ​◻​ ​ Widowed ​◻​ Separated

Applicant A  Applicant B 
First: Middle: Last: First: Middle: Last:

Date of Birth: Ethnicity: Date of Birth: Ethnicity:

Relationship to child(ren): Relationship to child(ren):

Home Phone: Cell Phone: Home Phone: Cell Phone:

Home Address: Home Address:

City, State, Zip-plus 4:  City, State, Zip-plus 4: 

Occupation: Occupation:

Employer/School Name: Employer/School Name:

Work Phone: Work Phone:

Work Address: Work Address:

City, State, Zip: City, State, Zip:

Applicant A – Income Verification Applicant B – Income Verification

Wages per month: $ ​_______________ Wages per month: $ ​_______________

CalWORKS (Cash Aid) for Parent per month: $ ​_______________ CalWORKS (Cash Aid) for Parent per month: $ ​_______________

Child/Spousal Support per month: $ ​_______________ Child/Spousal Support per month: $ ​_______________

Unemployment per month: $ ​_______________ Unemployment per month: $ ​_______________

Disability per month: $ ​_______________ Disability per month: $ ​_______________

Social Security per month: $ ​_______________ Social Security per month: $ ​_______________

Other Income: $ ​_______________ Other Income: $ ​_______________

TOTAL Monthly Gross Income (before taxes): $ ​_______________ TOTAL Monthly Gross Income (before taxes): $ ​_______________

Other adults living in the home:

Name____________________________ Relationship to Child____________________ Gross Monthly Income: _____________
Name____________________________ Relationship to Child____________________ Gross Monthly Income: _____________
 List all children under the age of 18 living in the home. Foster families only need to list 
child needing care and brothers and sisters of that child.
Child you wish to enroll:
First Name: Middle Name: Last Name: Date of Birth:

Sex: ​◻​ Male ​◻​ Female Ethnicity:

List any special needs: 

Does your child have an Individual Education Plan (IEP)? ​◻​ Yes ​◻​ No 
Does your child have an Individual Family Service Plan (IFSP)? ​◻​ Yes ​◻​ No 

Other children in the home:

First Name: Middle Name: Last Name: Date of Birth:

Sex: ​◻​ Male ​◻​ Female Ethnicity:

List any special needs: 

Does your child have an Individual Education Plan (IEP)? ​◻​ Yes ​◻​ No 

Does your child have an Individual Family Service Plan (IFSP)? ​◻​ Yes ​◻​ No 

Other children in the home:

First Name: Middle Name: Last Name: Date of Birth:

Sex: ​◻​ Male ​◻​ Female Ethnicity:

List any special needs: 

Does your child have an Individual Education Plan (IEP)? ​◻​ Yes ​◻​ No 

Does your child have an Individual Family Service Plan (IFSP)? ​◻​ Yes ​◻​ No 

Other children in the home:

First Name: Middle Name: Last Name: Date of Birth:

Sex: ​◻​ Male ​◻​ Female Ethnicity:

List any special needs: 

Does your child have an Individual Education Plan (IEP)? ​◻​ Yes ​◻​ No 

Does your child have an Individual Family Service Plan (IFSP)? ​◻​ Yes ​◻​ No 

Other children in the home:

First Name: Middle Name: Last Name: Date of Birth:

Sex: ​◻​ Male ​◻​ Female Ethnicity:

List Any Special Needs: 

Does your child have an Individual Education Plan (IEP)? ​◻​ Yes ​◻​ No 

Does your child have an Individual Family Service Plan (IFSP)? ​◻​ Yes ​◻​ No 

Parent/Guardian Signature: Date:

Submit to: ​Revised 5/14/2020

Panama-Buena Vista Union School District
4200 Ashe Road
Bakersfield, CA 93313
Phone: (661) 831-8331 Ext. 6297