NETTLETON PRE-K APPLICATION w/COPA 2025-2026

NETTLETON PRE-K

APPLICATION
2025-2026 School Year
Campus Locations:

Fox Meadow Elementary

2305 Fox Meadow Lane, Jonesboro, AR 72404

870-910-7817

Director: Jennifer Gray

Site Director: Joshua Goodon

Steam Elementary

2305 Vera Street Jonesboro, AR 72401

870-910-7831

Director: Jennifer Gray

Site Director: Jordan Gardner

University Heights Elementary

300 Bowling Lane, Jonesboro, AR 72405

870-910-7823

Director: Jennifer Gray

Site Director: Sarah George

ATTENTION: COPA Application needs to be filled out in conjunction with this form. Please be sure to do this. https://arkansas.mycopa.com/familyPortal/childCare.epl

**Please upload the following items after submitting this application. Application Will NOT be considered complete until all items are provided.**
- Birth Certificate/Hospital Record
- Social Security Card
- Immunization Record (Current/up to date)
- Physical (within last 12 months)
- Three Proofs of Address
- Insurance Card
- $50.00 Non-Refundable application fee | visit nettletonps.info/prekdeposit25
If applying for ABC Free Tuition (Income Based) the following is also needed:
- Proof of Income for every adult in the home (acceptable items include most recent W-2, most recent tax return, recent 30-day pay stubs or Notarized No-Earned Income Statement form)
- Pay stubs must be consecutive and within 30 days of application date.
- Verification of income is required for all guardians in the household.

Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Is the student a foster child or adopted?*

YesNo
Mother (Guardian’s) Information
Name:*

First NameLast Name
Lives with child?:*

YesNo

Father (Guardian’s) Information
Name

First NameLast Name
Lives with child?:*

YesNo

Emergency Contacts (Person to call if parent can not be reached). Will be able to enter up to four contacts.
1st Contact*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code

2nd Contact*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code

3rd Contact*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code

4th Contact

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Caregiver Information

(Person the child lives with the majority of the time.)
Name*

First NameLast Name
Email
example@example.com

Secondary Caregiver Information
Name

First NameLast Name

What concerns do you have for your child?

PREGNANCY/BIRTH HISTORY:
Were there any complications during or following the pregnancy?*

YesNo
If Yes, please explain
Birthweight*
Duration of Pregnancy*
In walking, talking, and coordination did your child seem*

SlowAverageQuicker than average
If difficulties, please explain

Family Data
Father / Guardians Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Occupation*
Work Phone*
Please enter a valid phone number.
Mother / Guardians Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Occupation*
Work Phone*
Please enter a valid phone number.
Child lives with*

FatherMotherBoth ParentsOther
SIBLINGS AND OTHERS LIVING IN THE HOME

(LIST EVERYONE LIVING IN THE HOME)
First Name Last Name Age Grade Gender Relationship
First Name Last Name Age Grade Gender Relationship
First Name Last Name Age Grade Gender Relationship
First Name Last Name Age Grade Gender Relationship

Current Medications:
Medication 1

Medication Name

Street Address Line 2

DosageDuration

Reason Taking
Medication 2

Medication Name

Street Address Line 2

DosageDuration

Reason Taking
Medication 3

Medication Name

Street Address Line 2

DosageDuration

Reason Taking
Medication 4

Medication Name

Street Address Line 2

DosageDuration

Reason Taking
Does your child wear*

GlassesContactsNone