Murfreesboro City Schools
Ruth Bowdoin Preschool Program
Thank you for your interest in the Murfreesboro City Schools Preschool Program. We
are excited about the coming year. Our preschool classrooms will be located in
several schools for the 2015-2016 school year. The school locations for the
classrooms are tentative and will depend on space available. We will continue to offer
classrooms at our off site locations at Mercury Court, Oakland Court and Franklin
Heights. Children who reside within the Murfreesboro city limits and meet the
eligibility requirements, regardless of your child’s zoned school, may be placed in a
classroom based on location, zones, and proximity as long as space is available.
At this time all PreK classrooms are fully enrolled. However, we are accepting
applications for the waiting list as openings do occur. Please turn in completed forms
with required documentation at the Murfreesboro City Schools Central Office after
August 8th between the hours of 8:00 and 4:00. If a qualifying space becomes
available, you will be contacted at that time.
If you have questions, you may contact us by email at Preschool@cityschools.net.
INSTRUCTIONS FOR APPLYING FOR PREK
Please be sure to read all instructions carefully and bring all appropriate
documentation when you return your application.
Your child must be 4 years old on or before August 15, 2015. You must live within
the city limits of Murfreesboro and be zoned for a Murfreesboro City School.
Completing the application: *If you are downloading to print from the website there will 6 pages*
1) The Application should be filled out front and back. All information must be complete for the application to
be considered. Don’t forget to sign and date at the bottom of page 2.
2) The Income Eligibility Form must be completed for your application to be considered. Be sure you list ALL
individuals that live in your household in Part A.
Part B should be completed if you or your child participates in any of these programs. You must have official
documentation and case numbers to verify your participation in these programs. Be sure to bring that
documentation with you when you return your application. This information MUST be officially verified. Be
sure to sign on the back page of this form.
Part C is to be completed ONLY if you did not check any box in Part B. Read the instructions for Part C
carefully. Income for all family and household members must be listed. Income verification documentation as
listed in the box MUST be brought when you return your application.
*** Be sure to check the boxes for the documentation you are providing for Part B or C
When you return your Application you must bring the following :
We will be keeping all the documentation. Please bring COPIES, not originals of bills, birth
certificate, social security card, and income documentation.
Completed Application and Income Eligibility forms
Proof of your address. The only documentation that will be accepted is copy of an electric, water, or gas bill
with the parent’s name and the service address on it. These bills may be no more than 60 days old. If you
do not pay these bills, you must have a copy of your official lease in the parent/guardian’s name.
• Copy of Official Birth Certificate (not a mother’s copy). If your child was born in Tennessee, a birth certificate may
be obtained at the Rutherford County Health Department.
• Copy of your child’s Social Security card
* Copy of appropriate documentation to verify the information you provided on the Income Eligibility form from either
Part B or Part C. This documentation should include either your DHS letter confirming your child’s enrollment in a
public assistance program like food stamps or Families First. If you do not receive public assistance, we require
verification of income. You may bring your 2014 W2 or 1040 or 1040A tax return.
•
•
* All applicants will be considered for additional services or slots provided or funded by partnering
agencies, therefore, we ask that you submit a W-2 or 2014 tax return in addition to state required
documents (or other supporting documents). Submitting these will expedite the processing of applications.
Why we require documentation to support your application:
*Only children who are 4yrs. old, but not yet 5, by Aug. 15, 2015 are eligible. A
birth certificate is the only documentation recognized by the state.
*Only children who live within the city limits of Murfreesboro are eligible for the
program. A utility bill, electric/gas/water, issued within the last 60 days are the
only documents accepted. If you do not pay utilities, we require a copy of a current
lease.
*In addition we require information on your family income. Please see the information
below excerpted from the website of the TN Dept. of Education:
Enrollment in the Voluntary Pre-K program is based upon a child’s eligibility as identified in TCA 49-6101─104. Available space in each school system is limited and is based on the funding awarded each year
through a grant process.
Enrollment Priority Requirements
Pursuant to state law 49-6-101: priority is given to students identified as economically disadvantaged/ low
income. This identification is based on income levels set each year by the Department of Health and
Human Services and used during the application process to determine income eligibility for enrollment.
OFFICE USE ONLY
DOB CK_________________________
Address CK______________________
Zone__________________________
Murfreesboro City Schools Preschool Program
( A Partner with Mid-Cumberland Head Start )
APPLICATION MUST BE COMPLETE AND ACCURATE TO BE CONSIDERED
Child’s Name as it appears on the birth certificate:
______________________________________________________________________
First
Middle
Last
Date of Birth ______________ Sex_____ Race______ Phone #___________________
Social Security # ____________________ Language Spoken at Home______________
List any special needs____________________________________________________
Does your child live with (circle all that apply): Mother Father Grandparents Guardian
Is your child able to handle toileting habits independently: (circle one) Yes No
Mother/Guardian Information
Name ________________________________ Phone (
) -_____ - _________
Address______________________________________________ Zip Code__________
Place of Work____________________________ Work phone_____________________
Father/ Guardian Information
Name _______________________________ Phone (
) - ______ -__________
Address________________________________________________ Zip Code________
Place of Work____________________________ Work phone_____________________
Parent Email address ______________________________________________________
Extended School Program (ESP): Will your child need extended childcare?
________My child will not need ESP
OR
My child will need care:____Morning only
____ Afternoon only ____Morning and Afternoon
Siblings currently attending Murfreesboro City Schools:
Name____________________________________Grade_________School_________________
Name____________________________________Grade_________School_________________
Name____________________________________Grade_________School_________________
Are any siblings currently on an approved zone waiver for the above listed schools. YES or NO
Additional Contact Information:
Name_________________________ Phone________________
Relationship___________
Name_________________________ Phone________________
Relationship___________
Name_________________________ Phone________________
Relationship___________
Health Information- Please complete carefully and check ALL that apply:
_____Allergies? List: ___________________________________________________________
What happens? __________________________ Is Epi-pen prescribed? Circle: Y or N
_____Asthma? Is Inhaler used? Circle: Y or N If yes, how often?________________________
What medications are taken for Asthma? ____________________________________________
_____Diabetes? Circle: Type I or Type II What medications are taken? ____________________
_____Special procedures? Describe ________________________________________________
_____ADD or ADHD? What medications are prescribed? _______________________________
Will medication be taken at school? Y or N When? ______________________________
_____Seizures? What type? _________________ Date of last seizure ____________________
Is Diastat prescribed? Y or N
What other medications are prescribed? ______________
_____Episode of loss of consciousness? When? _____________________________________
List any other medical problems or concerns which you would like the school to know about:
_____________________________________________________________________________
Student’s Doctor______________________________________ Phone____________________
Student’s Specialist___________________________________ Phone ____________________
Student’s Dentist______________________________________
Please contact the school for Medication or Procedure Forms if your child requires
medication or procedures during the school day.
I understand that I am required to provide transportation to and from preschool for my child every day. I
have read the instructions for the application process and understand that I must provide all necessary
documentation for my child’s application to be considered. I agree to comply with all regulations and
policies of the Murfreesboro City Preschool Program. I understand that I may be contacted by MidCumberland Head Start for selection into a partnership slot. I give my permission for Murfreesboro City
Schools to verify any information on the application, including income. I understand that acceptance into
this school is contingent upon my city residency. If I move outside the city limits during the school year, my
child will no longer be allowed to attend the preschool. I understand that unacceptable attendance may be
grounds for removal from the program.
________________________________________________________________
Parent/Legal Guardian’s Name (print)
________________________________________________________________
Parent/Legal Guardian’s Signature
date
TN Department of Education
Office of Early Learning-­‐
Corrected
2015 US Health and Human Services Poverty Guidelines
*Annual income levels reflect 185% of the 2014 US Health and Human Services Poverty Guidelines, equivalent to reduced priced lunch criteria.
Household
Size
1
2
*Annual
Income
$21,775.00
$29,471.00
Monthly
$1,815.00
$2,456.00
Twice per
Month
$908.00
$1,228.00
Every two
weeks
$838.00
$1,134.00
Weekly
$419.00
$567.00
3
$37,167.00
$3,098.00
$1,549.00
$1,430.00
$715.00
4
$44,863.00
$3,739.00
$1,870.00
$1,726.00
$863.00
5
$52,559.00
$4,380.00
$2,190.00
$2,022.00
$1,011.00
6
$60,255.00
$5,022.00
$2,511.00
$2,318.00
$1,159.00
7
$67,951.00
$5,663.00
$2,832.00
$2,614.00
$1,307.00
8
$75,647.00
$6,304.00
$3,152.00
$2,910.00
$1,455.00
For each
additional
person, add
$7,696.00
$642.00
$321.00
$296.00
$148.00
This chart is to be used when reviewing the Pre-­‐K Income Eligibility application to determine if family meets income qualifications for "economically disadvantaged." Families making at or below the annual income amount, based on household size, meet the income eligibility criteria for participation in the Voluntary Pre-­‐K program for the 2015-­‐16 school year. Verification must include total income of all household family members as indicated on Pre-­‐K income THIS CHART MAY NOT BE USED FOR ELIGIBILITY FOR FREE or REDUCED PRICED LUNCH PROGRAM.
Meeting Income eligibility requirements does not guarantee acceptance into the VPK program due to limited space and the possibility of more students applying than seats available.
For Office Use Only
Please Circle One
Income Eligible:
Yes / No
2015-16
Application to Determine Income Eligibility for the Voluntary Pre-K Program
Completion of this form DOES NOT qualify your child for the Free or Reduced Meal Program.
application is not a guarantee of acceptance into the VPK program.
Name of Student:
Date of Application:
SSN of Student:
Date of Birth of Student:
Name of Applicant:
Relationship to Student:
Submission of this
Mailing Address:
City:
State:
Home
Phone #:
(
Work
Phone #:
)
(
Zip Code:
Cell Phone
#:
)
(
)
Part A - Family Information
Please list information for all other household members.
Section 1
Name(s) of ALL OTHER CHILDREN in the Household
Date of Birth
School
Grade
1.
2.
3.
4.
5.
Section 2
Name(s) of ALL OTHER ADULTS in the Household
Relationship to Student
1.
2.
3.
4.
5.
Total # of household members:
Part B - Program Participation
Please check (√) if Child /Family /Household member provides documentation of participation, in one or more of the following programs,
currently or during past school year (*Documentation required-See Part D).
(√)
(√)
(√)
Early Head Start
Foster Care
Head Start
Homeless
(√)
Migrant
Case #
Families First (TANF)
Food Stamps / EBT
Siblings met eligibility for Free or Reduced Price Meal Program in 2014-2015
*If submitting proof of qualifying for any of the above programs, you do NOT need to complete Part C.
Updated: January 31, 2014Feb 27,2015
ED-5476 Division of Special Populations
Part C - Total Household Income
Please list ALL INCOME of all household family members and how often income is received.
Any falsification of information concerning income, residence, birth certificate and/or completion of this application and other forms may be
reason for dismissal.
Income Instructions
From the list below, please write the Source of Income Code in the space provided to indicate the source(s) of income for each earning individual
in the household. Also, please write the Monthly Payment or Wage Amount. Multiply the Payment or Wage amount by the number months you
received the income and then calculate the Amount and the Total Annual Income.
Source of Income Codes
A.
GROSS work income
D.
Pension(s)
G.
Veteran's Benefits
J.
SSI Disability
B.
Unemployment
E.
Retirement
H.
Child Support
K.
Other - please list
C.
Workman's Comp
F.
Social Security
I.
Alimony
Name of Adult
Employer (if applicable)
Source of
Income
Code (See
list above)
Monthly Payment or
Wage Amount
$
-
Multiplied
by
(X)
↓
How many
months did you
receive this
income in the
last year?
Total Amount
X
$
-
$
-
X
$
-
$
-
X
$
-
$
-
X
$
-
$
-
X
$
-
Total Annual (Yearly) Income $
-
Part D - INCOME VERIFICATION
Please check (√) all documents submitted as Proof of Income or Program Participation.
Pay Stub / Verification of pay by employer
Retirement Documentation
Foster Care Reimbursement
W-2 Form
Social Security
SSI Documentation
Income Tax Form 1040A or 1040
Veteran's Benefit Letter
TANF Documentation
Unemployment Compensation
Child Support
AFDC / Public Assistance Payment
Workman's Compensation Documentation
Alimony Documentation
TennCare Verification
Pension Stubs
Other (Specify): →
I certify that the above information in this application is correct. I further understand that any falsification of information concerning income,
residence, birth certificate and/or completion of this application and other forms may be reason for dismissal from Tennessee's Voluntary Pre-K
Program.
Printed Name of Applicant:
SSN #:
Signature of Applicant:
Date:
Name and Signature of LEA employee reviewing this application
I certify that I have examined the above income documentation and verification information.
forms must be maintained in accordance with FERPA.
Completed
Printed Name / Title of LEA employee:
Signature of LEA employee:
Date Reviewed by LEA employee:
Updated: January 31, 2014Feb 27,2015
ED-5476 Division of Special Populations
Solo para uso oficial
Please Circle One
Income Eligible:
Yes / No
2015-16
La solicitud para decidir la elegibilidad de los ingresos para la investigación preescolar voluntaria
Rellenar este impreso NO resulta en la clasificación del estudiante para comidas escolares gratis y a precio reducido.
Nombre del Estudiante:
Fecha:
Número del Seguro
Social de la Estudiante:
Fecha de Nacimiento:
(mes/día/año)
Nombre en letre de
molde del solicitante o
de uno de los padres:
Relación a estudiante
(padre/madre)
Direccion:
Ciudad:
Estado:
Teléfono de su casa:
(
Codigo Postal:
Teléfono de su trabajo:
)
(
Numero cellular:
)
(
)
Parte A - Información de la Familia
Por favor, lista información sobre su familia
Sección 1
Nombres de otro niños en su casa:
Fecha de Nacimiento
Nombre de Escuela
Grado
1.
2.
3.
4.
5.
Sección 2
Nombres de otros adultos en la casa:
Relación a estudiante (por ejemplo: padre/madre):
1.
2.
3.
4.
5.
Cuantas personas que viven en la casa:
Parte B - participación en el programa
Por favor, marca (√) si su hijo/a o su familia participa en uno de esos programas (la documentación)
(√)
(√)
(√)
Early Head Start
Foster Care
Head Start
Sin Hogar
(√)
Migratorio
Case #
Families First (TANF)
Food Stamps / EBT
Los hermanos del estudiante reciben comida gratis o precio reducio en la escuela (NSLP) en 2014-15.
Si presenta documentación de las programas como se dice más arriba, no es necesario completar Parte C.
Updated: February 27, 2015
ED-5476 Division of Special Populations
Parte C - Suma de Ingresos de Hogar
Por favor, lista TODOS LOS INGRESOS de la familia y con qué frecuencia recibe.
Falsificacion de la informacion de ingreso, residencia, o otro preguntas resulta en dimisión de la investigación.
Ingreso Instrucciones
De la lista debaja, por favor escriba El Codigo de los Ingresos en el espacio e indique el tipo de ingreso recibe. Tambien, por favor escriba el
suma en un mes y multiplica de el numbero de meses que recibe este typo de ingreso. Calcula el total por un año.
Codigo de los Ingresos
A.
Ingreso del trabajo
D.
Pension(es)
G.
Beneficios de
Veteranos
J.
Ingresos del seguro de discapacidad
B.
Cheque for desempleo?
E.
El fundo de retiro
H.
Manutencion de los
hijos
K.
Otro - por favor, lista
C.
Compensacion al
Trabajadore
F.
Seguro Social?
I.
Alimentos
Nombre de Adulto
Empleador (si aplicable)
Codigo de
Ingresos
Multiplica
de:
Pago en un mes
Cuantos meses
usted recibe
este ingreso
↓
Suma
$
-
X
$
-
$
-
X
$
-
$
-
X
$
-
$
-
X
$
-
$
-
X
$
-
Suma de Ingresos en un año $
-
Parte D - Verificación de los Ingresos
Por favor marca (√) todos que has presentado en sus comprobantes de ingreso.
Talon de pago/verificacion de empleador
Retiro Documentacion
Cuidado de crianza documentacion
W-2 Forma
Seguro Social
SSI Documentacion
Income Tax Forma 1040A or 1040
Letra de los Veteranos
TANF Documetacion
Desempleo Forma
Manutencion de los hijos
AFDC / Public Assistance Payment
Documentación de Compensacion al Trabajadore
Documentación de los Alimentos
TN Care Verificacion
Pension(es)
Otro (Lista): →
Certifico que toda la información en esta solicitud es verdadera y correcta. Entiendo que falsifico intencionalmente de los ingeresos o la
dirección puede resulta in dimisión de la programa Pre-K.
Nombre en letre de molde del
solicitante:
SSN #:
Firma de solicitante:
Fecha:
Sólo por uso oficial. No escribe debajo de esta linea.
Name and Signature of LEA employee reviewing this application
I certify that I have examined the above income documentation and verification information.
forms must be maintained in accordance with FERPA.
Completed
Printed Name / Title of LEA employee:
Signature of LEA employee:
Date Reviewed by LEA employee:
Updated: February 27, 2015
ED-5476 Division of Special Populations