Title I and NCPre-K Application for 2017-2018 School Year

Required documents: proof of residence, birth certificate, immunizations, social security number, and income. Your child must be 4 on or before August 31, 2017.

Please print. Please complete all lines.

Child’s Legal Name, Last: / First: / Middle:
Date of Birth: / Was this child born in the U.S.A.? / Sex:
Male Female / Child’s Social Security Number: / Child’s Race: White Black
Hispanic Asian Indian
Child lives with: / Relationship to the child:
Street Address: / How long have you lived at this address?
City: / State: / Zip Code: / County of residence:
Phone: Home Work
Cell Text msg ( ) - / Alternate Phone: Name and relationship:
Home Work
Cell Message ( ) -
Is the child currently in child care/day care/ Head Start or any other Pre-K Program? No Yes / Did the child have difficulty adjusting to previous child care/day care/ Head Start? No Yes, describe: ______
Has the child previously been in child care/day care/ Head Start or any other Pre-K Program? No Yes
If yes to the questions above, please list:
Name of Child Care Program(s) :
How long attended
(For multiple listings use back of questionnaire)
What was last date attended child care :______/ Does the child have any serious illnesses or handicapping conditions? * No Yes, Please describe:______
*physician verification is required
Has the child had a formal developmental evaluation? (Ex.: CDSA)
No Yes
Child’s Health
Status:(choose one) / child has no significant health concerns / child is seen or being seen by a pediatric
specialist for a chronic health concern / child is identified as mentally or physically
chronically ill or medically fragile

Employment Status

/

Highest Level of Education

/ Language(s) Spoken
Mother’s Information:
Name: ______
Marital Status: Single Married Separated Divorced
Currently residing in the home with the child? Yes No / Employed Full-time
Where______
How long______
Employed Part-time
Where______
How long______
Unemployed Disabled / Still in high school
Dropped out of school
High School Diploma
GED
Some college
College Graduate
Level: AA BS MS / Check all that apply:
English
English as a
2nd Language
Spanish
Other: ______
Father’s Information:
Name: ______
Marital Status: Single Married Separated Divorced
Currently residing in the home with the child? Yes No / Employed Full-time
where______
Employed Part-time
where______
Unemployed
Disabled / Still in high school
Dropped out of school
High School Diploma
GED
Some college
College Graduate
Level: AABS MS / Check all that apply:
English
English as a
2nd Language
Spanish
Other: ______
Family Size (how many in actual family): / Gross Income of Child’s Actual Family:______
Weekly Monthly Yearly / Number of Adults (age 18 & over)
residing in Child’s Household:
Has one or more parent been placed on a deployment list ___yes or __no / Number of Children (under age 18) residing in Child’s Household:

Parent/Guardian Acknowledgement

I understand by submitting this application that my child will be assessed for the NCPre-K Pre-Kindergarten program. I understand if my child qualifies for the NCPre-K program, parent involvement will be critical to the success of my child. I/We will commit to participate as required by the criteria of the Pre-K program. (Proof of Income is required)

Assurance Statement:

I CERTIFY THAT I AM THE PARENT/GUARDIAN OF THE CHILD FOR WHOM THIS APPLICATION IS BEING MADE AND THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT.

______

Parent/Legal Guardian (required)Date

Signature and Verification of income are required by the state NCPre-K program.

Contract Administrator’s Signature: ______Date: ______