Application For Regional School-Based Preschool Services
Service Area: Augusta, Bath, Harrisonburg, Highland, Rockingham, Staunton, Waynesboro
(Note: WaynesboroCity residents can apply at their home elementary school using the school form)
Placement/Funding Partners: Head Start, Virginia Preschool Initiative, & Special Education
(This application may be shared with the host school division to determine the best preschool placement option for your child)
If you do not want this application and/or information shared for eligibility purposes please check here ______
Child’s Name ______Date of Birth ______
First Middle LastBirth Certificate # ______
State/Country ______
Social Security # ______Sex: ____ MaleRace: ____ Asian____ Black____ Other:
____ Female ____ White____ Biracial______
First/Primary Language: ______Ethnicity: _____ Hispanic _____ Non-Hispanic
Who has physical custody (who does he/she live with)? (list name(s) and address below)
Name(s): ______Relationship to child: ______
Address ______
Street/Route City State Zip
Telephone # ______Message # ______Cell/pager# ______Work # ______
Does the person(s) listed above also have legal custody? ______If not, who does? ______
Do have regular access to email/internet? ______Email Address: ______
City or County Residing In: ______Elementary School District ______
Has this child ever attended any other preschool program? ______Where? ______
Has this child ever been referred to or evaluated by the school system or other facility for special education, speech,
infant education, or preschool services?______When? ______Where? ______Outcome: ______
Does he/she have an IEP or are they currently receiving services for the diagnosis above? ______
Are you concerned about this child’s health, development, speech, or behavior at this time? Yes or No
If yes, why?:______
______
What type of medical insurance does your child have:______What type of dental insurance does your child have:______
Additional reasons this child should be considered for Preschool Classroom Placement? ______
Who referred you to school-based preschool? ______
Household Profile:
Please list allindividuals residing in the home including the child, the child’s parent(s)/guardian, siblings and any other individuals who live in the home who are supported by the income of the parent(s)/guardian of the child and are related to the parent/guardian by blood, marriage, or adoption:
Date of BirthRelationship to School Attending or
NAME(mm/dd/yy)parents/guardians or Highest Grade Completed
______
______
______
______
Family Factors (check as many as apply):
_____One Parent Unemployed_____Family does (or has) receive TANF (TANF # ______)
_____Both Parents Unemployed_____Family is receiving Supplemental Security Income (SSI)
_____No Drivers License Holder in Household_____Family has moved more than 2 times within the last year
_____Seasonal Employment or Migrant Work_____Family has nutritional needs
_____Single Parent (never married)_____Homeless family (street, car, shelter, hotel, friends/relatives)
_____Divorced /Separated Parent(s)_____Parent(s) have limited reading skills
_____Deceased Parent_____Parent has a long term or chronic illness
_____Child is/was in foster care_____Child or Family has Language Barrier (Limited English) _____ Child has a disability _____ Parental substance abuse history
_____Sibling has a disability_____Siblings are/have received Title I Reading Services
_____Parent has a disability_____Teen mother or father at child’s birth
_____Child has a medical condition_____Parent does not have GED or H.S. Diploma
_____Domestic Violence in the home_____Child has been abused (physically, sexually or emotionally)
_____Child or family is in counseling _____Family/Siblings qualify for free/reduced lunch at school
_____Child does not live with his/her parents_____Child or Siblings have been removed from the home
_____Parent(s) are in job training or school_____Housing Concerns: Overcrowded, NeedsMajor Repairs, Lack of heat, etc
_____Child weighed less than 5lbs at birth_____Parent absent from the home: works out of
_____Family is receiving WIC servicestown, long term hospitalization or military service
_____Incarcerated Parent(s)_____Family is receiving Food Stamps (Food Stamps # ______)
_____Child is receiving Medicaid or FAMIS_____ Child does not have medical insurance
_____Child has never been to the Dentist_____No other preschool services available for this child
_____Child does not have a regular Pediatrician_____Child has no contact with one or both parents
VERIFICATION of all gross household income is requested for admission into preschool. Please check all that apply to individuals listed above and send in verification/proof with the application.
_____0 income (No income in the household at this time)
Verification Needed (A copy of your food stamps award letter or a notarized letter explaining your situation or send a copy of your most recent tax return)
_____All Other Income: Please List
Verification Needed (Tax return or W-2 or check stubs or child support order or TANF notice or Social Security award letter or unemployment compensation notice or letter from your employer or any other papers that prove your income amount for the family income received)
Name of person receiving income Place of employment How often is income received?Gross
Or type of incomeAmount?
______
______
______
If income verification is not provided you may not be considered for all preschool openings.
Confidentiality Statement: Information shared will be kept confidential unless a release is authorized in writing or it is requested by a court order.
THANK YOU FOR YOUR TIME IN COMPLETING THIS APPLICATION!
______
Parent/Guardian SignatureDate
If this application is filled out by someone other than the parent/guardian, please list your contact information below in case there are questions or more information needed. This is especially helpful if the parents speak a language other than English.
Name: ______Phone Number: ______
Return Application to:School -Based Preschool Enrollment
C/O Head StartPhone: 540-245-5162 ext 127
6 John Lewis Road800-405-8069
Fishersville, Virginia22939Fax: 540-245-5064
School-Based Preschool Services
6 John Lewis Road
Fishersville, VA22939
Service Area: Augusta, Bath, Harrisonburg, Highland, Rockingham, Staunton, & Waynesboro
Placement/Funding Partners:
Head Start, Virginia Preschool Initiative, Title I, Special Education
This application is for the school-based preschool in this service area. There is No Fee for preschool services in these schools.
1)Please fill out this application, entirely.
2)Attach proof of income (verification of income information is on the next page).
3)Applications are accepted year round, however, for earliest review please mail this application before April 15th.
4)If your child is accepted you will be notified in writing and the following items must be received prior to the first day of school:
- A Physical Exam
- Up to date Immunization Records
- A Dental Exam
- Copy of Birth Certificate issued from state of birth (hospital certificates not accepted)
- Copy of Social Security Card
5) If your child is not enrolled at the time you have applied he or she will be placed on the waiting list.
School-based Preschool is voluntary and not available for all children at this time due tolimited space in our classrooms.
- Children who are or will be four years old by September 30th of the enrollment year are given priority for enrollment.
- Eligibility is based on age, income level, and/or identified need. Children with or without disabilities are encouraged to apply.
*We do not discriminate against an applicant because of race, color, creed, national origin or handicapping condition. Applicants are enrolled based on criteria mandated by the state, local, and federal government, including age, family income level, and/or greatest need.
Mail this application to:School Based PreschoolPhone: 540-245-5162 ext 127
c/o Head Start800-405-8069
6 John Lewis RoadFax:540-245-5064
Fishersville, VA 22939