Susan Gray School Waitlist Form

Please complete a separate form entry for each child.

Parent's Name Parent's Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Information About Your Child
Has your child been born?

Has your child been born? Yes No
Due Date
Child's Name Child's Name First Last
Gender
Ethnicity

Ethnicity Hispanic or Latino Not Hispanic or Latino
Race (select one or more of the following)

Race (select one or more of the following) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Birthdate Birthdate / MM / DD YYYY
At how many weeks was your child born?
We would like to know more about your child. The Susan Gray School is an inclusive preschool where children with and without developmental disabilities learn together. Does your child have a diagnosis?
Has your child been screened or qualified for Tennessee Early Intervention Services (TEIS)?
What is the diagnosis?
Does your child have an IFSP/IEP? If so, what county?
Does your child have a TEIS Service Coordinator? If so, who?
Is your child currently enrolled in the SGS outreach Program?
Do you have concerns about your child's development?
Additional Information
How did you hear about our program?
We enroll children who receive Child Care Certificates from the Department of Human Services. Does your family currently participate in the Child Care Certificate program?
Are you interested in learning more about eligibility requirements for tuition support from the Child Care Certificate program?
Would you like to schedule a tour? If yes, someone from the school will contact you to schedule a tour.

Susan Gray School Waitlist Form

Susan Gray School Waitlist Form

Information About Your Child

Additional Information