Preschool for All Sample Eligibility Form
Instructions for developing an eligibility form.
This is a sample form. Each program will develop its own eligibility form that consists of weighted criteria based
on the risk factors present in their own community. The weighted criteria form will be completed with
information obtained from the parent interview form and information gleaned from the child screening
instrument. Programs will serve those children and families most in need in the community determined by
those exhibiting the most at-risk factors as determined by a weighted criteria form uniquely created by each
individual program. Programs will develop weighted criteria based upon the risk factors required in the PFA
RFP, the risk factors present in the community, and those factors identified by research as causing children and
families to be at risk.
Programs will utilize the individualized weighted criteria system for (a) Enrolling families identified as having
most at risk factors, (b) Ensuring families with the most at risk factors are prioritized on a waiting list (if
applicable). After a family is enrolled in the program they are allowed the opportunity to continue services for
the duration of the program until Kindergarten eligible or otherwise defined in the child’s IEP. The family may
voluntarily leave the program. Screening for eligibility and this form are only completed one time.
Child’s Full Name: _______________________________ Birth Date: ______________ Age: ___________
School/Program Name :__________________________________________________________________
Parent Name: __________________________
Parent Name: __________________________
Phone: _______________________________
Phone: ________________________________
Address: ______________________________
Address: _______________________________
City_________________ Zip ______________
City_____________________ Zip ___________
The following are worth 50 points each:
(If a child presents with any one of these risk factors (numbers 1-3) the family should be considered the highest
priority and be directly enrolled in the PFA program or placed at the top of the PFA waiting list.)
1.
_____
(50) Homeless (McKinney-Vento Homeless Education Assistance Act,
http://www.isbe.state.il.us/homeless)
2.
_____
(50) Ward of the state/foster child
3.
_____
(50) Two or more delays on research-based screening tool
The following are worth 5 points each:
4.
_____
(5) Low income (Qualifies for free and reduced lunches, public housing, child care subsidy,
WIC, SNAP, TANF, Medicaid)
5.
_____
(5) History of child abuse or neglect
6.
_____
(5) History of domestic violence
7.
_____
(5) History of alcohol/drug abuse in family
8.
_____
(5) DCFS involvement
9.
_____
(5) Chronic or terminal illness of child
10. _____
(5) Chronic or terminal illness of family member
11. _____
(5) Child has documented disability/CFC referral
Illinois State Board of Education
Early Childhood Division
September 2013
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
(5)
25.
_____
(5)
Caregiver has disability
Caregiver has mental illness
Death in immediate family (parent, child, sibling)
Caregiver other than parent raising child
Teen parent at birth of first child
Low birth weight/failure to thrive
Recent immigrant or refugee family
English not spoken in home
Family active military
Parent incarcerated
Primary caregiver did not complete high school/ No GED
High mobility or transience
Program specific (This space is provided for programs to add community risk factors.)
___________________________________________________
Program specific (This space is provided for programs to add community risk factors.)
__________________________________________________
The following are worth 4 points each:
26. _____
(4) Receiving services from another agency
Explain _______________________________________________________
27. _____
(4) Socially or geographically isolated
28. _____
(4) Other Health Issue
Explain _______________________________________________________
29. _____
(4) Program specific (This space is provided for programs to add community risk factors.)
___________________________________________________
The following are worth 3 points each:
30. _____
(3) One delay on screening tool
31. _____
(3) Single parent
32. _____
(3) Program specific (This space is provided for programs to add community risk factors.)
___________________________________________________
_____
TOTAL SCORE
Notes:
_______________________________________
Staff Signature
Illinois State Board of Education
_______________________
Date
Early Childhood Division
September 2013