/ Roanoke County Public Schools
Pupil Personnel Services
5937 Cove Rd. NW
Roanoke, VA 24019
Phone: (540) 562-3700 Fax: (540) 562-3957

Dear Parent or Guardian:

Thank you for your interest in Roanoke County Public Schools’ Virginia Preschool Initiative Program. Attached you will find the requested application for the program. Also included is a release of information for Head Start, with whom Roanoke County Public Schools collaborate.

If your child qualifies and is accepted, he/she will attend a Roanoke County Public Schools Preschool site and may receive additional services through the Head Start Program.

Each year the funding for the Virginia Preschool Initiative Program is determined by the State Legislative Budget. Once the school division has been notified of funding, all applications received to that date will be processed and families will be informed of the status of their application.

In order to process the application, you must provide information for all questions asked. Not answering all questions could cause a delay in determining the family’s status for the program.

The completed application and supporting documents may be mailed, delivered, or faxed to:

Roanoke County Public Schools

Preschool Program

5937 Cove Rd.

Roanoke, VA 24019

FAX: (540) 562-3957

If you have any questions, please call Jennifer Durrance at (540) 562-3900, ext. 44701 or myself at (540)562-3900, ext. 44702.

Sincerely,

Dana M. Kreklow

Preschool Program Coordinator

Virginia Preschool Initiative Application

Roanoke County Public Schools

***For this program: Child MUST be 4 years old on or before September 30th***

Applicant & Family Member Information

* If a family has more than one child applying for services, please complete a separate copy of this form for each applicant.

Applicant

First / Middle / Last / Birthday / Gender
What is the primary language spoken in the home? / Medicaid Eligibility / Medicaid # / Is the child in Foster Care? / Is the child being raised by someone other than the biological parent(s)? / Single Parent Family
o Not Eligible
o On Medicaid / o Yes; DSS Contact Name ______
o No / o Yes
o No / o Yes
o No
Did parent graduate from High School? / Is the parent on Military Deployment? / Is the parent incarcerated? / CURRENT Physical, Emotional, Sexual, or Substance Abuse in the home / Is the family homeless? / Child has a current signed IEP
o Yes
o No / o Yes
o No / o Yes
o No / o Yes
o No / o Yes
o No / o No
o Yes, date: ______

Primary Adult

First / Last / Birthday / Gender
Employment Status / Child's Relationship / Custody / Does the adult live with the family? / Marital Status
o Full-time
o Part-time
o Unemployed
o Student
o Retired or Disabled / o Biological/Adopted/Step
o Foster
o Grandchild
o Other Relative
o Other / o Yes
o No
/ o Yes
o No / o Single
o Married
o Divorced
o Separated
Email Address:

Secondary Adult

First / Last / Birthday / Gender
Employment Status / Child's Relationship / Custody / Does the adult live with the family? / Marital Status
o Full-time
o Part-time
o Unemployed
o Student
o Retired or Disabled / o Biological/Adopted/Step
o Foster
o Grandchild
o Other Relative
o Other / o Yes
o No
/ o Yes
o No / o Single
o Married
o Divorced
o Separated
Email Address:

*Please complete for each child in the family. For more than 4 additional children, please attach the information to the back of this form.

Additional Child (Non-Applicant)*

First / Last / Birthday / Gender

Additional Child (Non-Applicant)*

First / Last / Birthday / Gender

Additional Child (Non-Applicant)*

First / Last / Birthday / Gender

Additional Child (Non-Applicant)*

First / Last / Birthday / Gender

Family Information and Income

Family Information
Family Living Address / ZIP / City / State
Family Mailing Address
Same as living? / Family Mailing Address / ZIP / City / State
o Yes o No
Phone Number(s) / Type (check one) / Name of Person / Opt in for Text Messages
o Cell o Home o Work o Other ______/ o Yes o No
o Cell o Home o Work o Other ______/ o Yes o No

***Proof of Income MUST be provided***

Family Income
Family
Member / Amount
(Gross) / Per ( for example: week, month, year) / Annual Amount / Description (for example: SSI, Job, Child Support) / ***Verification (for example: W2, check stub) / Note
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
Income Notes

Certification: I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.

Parent/Guardian Signature Date
© 2015 Management Information Technology USA, Inc. 11/2/2016

/ AUTHORIZATION FOR RELEASE/EXCHANGE OF
RECORD INFORMATION
PLEASE COMPLETE THIS REQUEST BY LEGIBLY PRINTING IN THE APPROPRIATE SPACES.
Release effective until otherwise notified. / GU.3-134-10/09
SCHOOL USE ONLY:
______DATE SENT
____Mail ____FAX ___INDV

Student Name: Last First Middle

VA

Street Address City State Zip Code

Area Code and Telephone Number Date of Birth

N/A

Current/Last School Attended Date Graduated/Withdrew

Roanoke County Public Schools are hereby authorized to release or exchange the following specified information with:

Head Start 540-345-6781 ext 4360

Name Telephone Number

145 West Campbell Ave., PO Box 2868, Roanoke, VA 24001

Complete Address

INFORMATION OR RECORDS

Official Scholastic Record (names; address; birth date; grade level completed; grades; class standing; attendance record; standardized and aptitude test scores such as PSAT, AP; school, community activities; work experience)

State Testing Number

Health-Physical Fitness Data: Certificate of Immunization

Intelligence, Aptitude, Interest Test Scores

Social History (if available)

Legal, Psychological, Psychiatric, and Medical Reports (if applicable)

State required reports of evaluations and other pertinent reports and programs for exceptional students

I authorized all standardized SAT, SAT subject tests, and ACT tests scores to be released with the transcript.

I do not authorize any standardized SAT, SAT subject tests, or ACT tests scores to be released with the transcript. I understand that I will be responsible for requesting all scores to be sent from the appropriate testing organization and will research college requirements for the release of theses scores.

Other

The reason for this disclosure is: to facilitate an exchange of information to assist with educational planning

I understand that I have the right to request a hearing to challenge the content and accuracy of the school record requested.

______

Date Parent’s/Guardian’s/Eligible Student’s Signature

Return information to: Roanoke County Public Schools, 5937 Cove Road, Roanoke, VA 24019

540-562-3900 ext. 44701

IN-SCHOOL USE ONLY (form is on the intranet) RELEASE EFFECTIVE FOR CURRENT SCHOOL YEAR ONLY