FREDERICKSBURG CITY PUBLI SCHOOLS PRESCHOOL PROGRAMS

HEAD START/VIRGINIA PRESCHOOL INITIATIVE/EARLY CHILDHOOD PROGRAMS

School Year: 2014-2015 Application # ______

Fredericksburg City Public Schools Preschool Programs do not discriminate on basis of race, national origin, sex, or disability.

Please consider my child for the following program (s). I understand that there are limited spaces available in most programs.

o A. All programs for which he/she is eligible o B. Head Start (oAge 3 o Age 4)

o C. Early Childhood Special Education o D. Virginia Preschool Initiative (VPI)

**If you checked A, B, or D, please provide parent’s annual gross income.

Program Requirements for all Preschool Enrollment: Must be a resident of Fredericksburg City (need proof of address) and meet program eligibility requirements. The school division requires an up-to-date immunization record and a current physical. Head Start and VPI will also require a dental examination upon enrollment.

Preschool Programs Offer: Monday-Friday from September – June, transportation, breakfast and lunch, highly qualified teachers and support staff. Head Start also offers comprehensive services for children and families. Head Start is required to accept a minimum of 10 (ten) percent students with an identified disability. THERE IS NO APPLICATION OR TUITION FEE.

Child’s Full Name: ______Child’s Date of Birth: ____/____/_____ (MM/DD/YEAR)
Street Address: (include City, State & Zip) ______Gender: M / F
PO Box (if applicable) ______
Home Phone #: ______/______/______Cell Phone: ______/______/______Work #:_____/______/______
Name: ______Emergency # ______/______/______
Child’s Race: (Circle all that apply) Asian, Black, White, Bi-Racial/Multi-Racial, American Indian/Alaska Native,
Black/Hispanic, White/Hispanic, Hawaiian/Pacific Islander, Other ______
Ethnicity: Hispanic □ Yes □ No Country of Origin/Nationality ______
Child’s Primary Language: ______Parent’s Primary Language: ______
In what language would you prefer we communicate to you? ______
Does your child have Medicaid: ______FAMIS: ______Other Insurance: _____ No Insurance: _____
Medicaid Number ______Private Insurance Number ______
Child’s Doctor’s Name ______Child’s Dentist’s Name ______
Name of Mother: ______Mother’s Date of Birth: _____/______/______
Parental Status: (Please circle one) Single Parent Two Parent Married Divorced Separated Widowed
Check all that apply: □ Lives with family □ Provides financial support □ Current Teen Parent
Parent Education: (Circle One) Grade: 1- 6 7- 9 10 - 12 HSD/GED AA BA/BS MS
Employment: (Circle One) Full-time, Part-time, Seasonal, Other: ______Place of Employment: ______
Legal Custody: □ Yes □ No Custodial Parent: ______Relationship to child: ______
Name of Father: ______Father’s Date of Birth: ______/______/______
Parental Status: (Please circle one) Single Parent Two Parent Married Divorced Separated Widowed
Check all that apply: □ Lives with family □ Provides financial support □ Current Teen Parent
Parent Education: (Circle One) Grade: 1- 6 7- 9 10 - 12 HSD/GED AA BA/BS MS
Employment: (Circle One) Full-time, Part-time, Seasonal, Other: ______Place of Employment: ______
Legal Custody: □ Yes □ No Custodial Parent: ______Relationship to child: ______
Number of people in family: Parents: ______Children: _____ Total: _____ Number in household: _____
Family means for the purposes of the regulations in this part all persons:
(i) Living in the same household who are:
(A) Supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program; or
(B) Related to the child by blood, marriage, or adoption
Adult Name: ______DOB ______Adult Name: ______DOB ______
Adult Name: ______DOB ______Adult Name: ______DOB ______
Child’s Name: ______DOB ______Child’s Name: ______DOB ______
Child’s Name: ______DOB ______Child’s Name: ______DOB ______

Is there any additional information about your child that you would like us to know? ______

OVER

Do you have concerns about your child’s development?  Yes  No

If so, please explain: ______

______

Does your child have an IEP (Individualized Education Plan/IFSP

Individual Family Services Plan)?  Yes  No

All programs seek to serve children with disabilities or special needs.

Was your child referred to our program?  Yes  No

If so, by whom/referring agency: ______

______

Check all that apply

 TANF

 SSI

 Homeless/Shelter/Transient

 due to loss of housing or economic hardship

 living w/family member/friend

 living in motel/hotel

 live in car

 Foster /Kinship Care

 Diagnosed Disability (Proof of documentation)

 Early Head Start Participant

 Age Eligible (4 years old)

 Age Eligible (3 years old ______months)

 Sibling of a current Head Start student? If so, who? ______

 No HSD/GED/

 Single Parent

 Unsafe/Unhealthy Living environment

 Domestic Violence

 Incarcerated Parent

 Pregnant Parent

 Current Teen Parent

 Community Agency Referral (provide referral)

 Department of Social Services/Food Stamps

 Health Department/WIC

 Military Family

 Have you had children that attended Fredericksburg

Head Start/VPI/ECSE Programs in the past?

If so, who/when: ______

Health problems such as asthma, (specify who and what) ______

______

Does your child have allergies i.e., food, medications, or allergies in general defined by a physician?  Yes  No

If so, please explain: ______

______

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Completing an application for the program does not guarantee

acceptance. Missing information may delay processing your

application.

Before a Head Start/VPI application can be processed,

the following information is required:

1. Birth Verification

2. Income verification such as any of the following to document family income:

Most recent monthly pay stubs or a letter from your employer, copy of all w-2

forms, tax return, documentation of SSI, SSA income, or proof TANF income

verification from DSS.

3. Verification of address

Income means gross cash income and includes earned income,

military income (including pay and allowances), veterans benefits,

Social Security benefits, unemployment compensation, and public

assistance benefits.

Please feel free to call if you have any questions regarding the application or need

assistance in completing. 540-372-1065.

Si necesita ayuda para llenar esta aplicaión favor de comunicarse con la oficina de

Head Start: 540-372-1065

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Please mail or bring completed application to:

Original Walker-Grant Early Childhood Center/Head Start

Original-Walker Grant School

200 Gunnery Road

Fredericksburg, VA 22401

540-372-1065 Phone or 540-372-1156 Fax

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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 information in

this application will be held in strict confidence within the agency and

is accessible to me during normal business hours.

***My signature gives permission for my local Department of Social Services to share information regarding my income. ***

______/______/_____ Parent/Guardian Signature Date
______/______/______
Signature of person completing this form Date
(Other than parent)

OFFICE USE ONLY

IDENTITY VERIFICATION

City/County/Country of Birth / State / Birth Date / Birth Certificate Number / Date Issued
Other Form of Proof / Date Documentation Viewed / Person Viewing Documentation
Child’s Birth Name
Mother’s Name / Father’s Name
Child Find Referral
 Fredericksburg  King George / By Whom: / Date
Application Reviewed by: / Income Reviewed: / Date Reviewed

2-20-14