FREDERICKSBURG CITY PUBLIC SCHOOLS PRESCHOOL PROGRAMS
HEAD START/VIRGINIA PRESCHOOL INITIATIVE/EARLY CHILDHOOD PROGRAMS
School Year: 2015-2016
Application # _______
Child Applicant
Child’s Name:
Last
First
Middle
Month / Day / Year
Date of Birth:
Country of Birth:
______________________________
Gender:
□ Male □ Female
Home Language: _________________________________
My child speaks: □ Very well □ Well □ Not Well □ Not at all
Race: (please check one) □ Asian
□ Black
□ White □ Native American □ Other _________________
□ Pacific Islander
□ Bi-Racial/Multi-Racial
□ American Indian
Ethnicity: □ No, not Hispanic or Latino □ Yes, Hispanic or Latino □ Mexican □ Puerto Rican □ Cuban
□ Dominican □ Other ____________________
Medicaid Eligibility: (please check one)
Does the applicant receive Medicaid? □ No □ Yes – Medicaid Number ______________________________________________
Other Health Coverage?
□ No □ Yes (please specify) _________________________________________________
Adult 1 This application is to be completed and signed by the adult who has legal custody of the applicant.
Parent/Guardian:
Last
Month /
First
Day /
Year
Date of Birth:
Gender:
□ Male □ Female
Country of Birth:
Middle
Relationship to Child
____________________________
Race:
Street Address:
Apt. #
City:
State:
Zip Code:
Email:
Home
Work
Cell
Telephone: ______________________________ ______________________________
____________________________
(Circle best number where you can be reached).
Please check one:
□ One Parent Home
□ Two-Parent Home
□ Foster parent
□ Other
Last Grade Completed: □ Below 9th grade
□ Grade 10-12
□ High School Diploma/GED
□ Some College
□ Bachelor’s degree
□ Master’s Degree □ Never attended school
□ Other (please specify) ________________
Currently Enrolled: □ Yes □ No
□ ABE
□ GED
□ College
Employment status:
□ Full-time
□ Part-time
Lives with child applicant: □ Yes □ No
Adult 2
□ Unemployed/other
If no, do you provide support?
Occupation: _______________________________
□ Yes □ No
Custody □ Yes □ No
Complete the following information for the other parent/adult acting in the role of parent.
Parent/Guardian:
Last
Month /
Day /
First
Year
Date of Birth:
Gender:
□ Male □ Female
Country of birth:
Middle
Relationship to Child
____________________________
Race:
Street Address:
Apt. #
City:
State:
Zip Code:
Home
Telephone: _______________________________
(Circle best number where you can be reached).
Please check one:
□ One Parent Home
Email:
Work
______________________________
□ Two-Parent Home
□ Foster parent
Cell
___________________________
□ Other
Last Grade Completed: □ Below 9th grade
□ Grade 10-12
□ High School Diploma/GED
□ Some College
□ Bachelor’s degree
□ Master’s Degree
□ Never attended school
□ Other (please specify) ________________
Currently Enrolled: □ Yes □ No
□ ABE
□ GED
□ College
□ Vocational School
Employment status:
□ Full-time
□ Part-time
□ Unemployed/other
Occupation: _______________________________
Lives with child applicant: □ Yes □ No If no, do you provide support? □ Yes □ No
Custody □ Yes □ No
Do you have any concerns about your child’s development? □ Yes □ No If yes, please explain: ______________________________
____________________________________________________________________________________________________________
Does your child have an IEP/IFSP (Individualized Education Plan/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: __________________________________________________________________________________
Please print the names of brothers and sisters of the child applicant.
(If additional space is needed, you may attach additional paper).
Last Name
First Name
Number of people in family: Parents: ______
Gender
Male/Female
Age
Date of Birth
Month/Day/Year
This child currently
lives with you?
□M□F
□ Yes □ No
□M□F
□ Yes □ No
□M□F
□ Yes □ No
□M□F
□ Yes □ No
□M□F
□ Yes □ No
□M□F
□ Yes □ No
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
Please check all programs/services that your family currently participates in/receives:
TANF/VIEW
□ Yes □ No
SSI
(Supplemental Security
Income)
□ Yes □ No
□ Formerly
Military Family
NO HSD/GED
□ Yes □ No
□ Yes □ No
Domestic
Violence
□ Yes □ No
Department of
Social
Services/Food
Stamps
□ Yes □ No
HOMELESS/Shelter/Transient
□ Yes □ No
due to loss of housing or
economic hardship
living w/family
member/friend
living in motel/hotel
live in car
Single Parent
□ Yes □ No
Foster/
Kinship Care
□ Yes □ No
Incarcerated
Parent
Early Head Start Participant
Pregnant Parent
□ Yes □ No
□ Yes □ No
Unsafe/
Unhealthy
Living
Environment
□ Yes □ No
Current Teen
Parent
□ Yes □ No
If so, who?
______________________
Health problems
such as asthma,
(specify who and what)
□ Yes □ No
□ Yes □ No
Have you had children that
attended Head
Start/VPI/ECSE Programs
in the past? □ Yes □ No
If so, who/when:
______________________
_____________
WIC
□ Yes □ No
ID #
_____________
□ Yes □ No
Sibling of a current Head
Start student?
□ Yes □ No
SNAP
(FOOD
STAMPS)
Age Eligible
(3 years old
______ months)
Age Eligible
(4 years old)
□ Yes □ No
□ Yes □ No
Diagnosed
Disability
□ Yes □ No
Community
Agency
Referral
(provide
referral)
□ Yes □ No
Child Care
Status
□ Receiving
□ Need
□ Funding
through DSS
If so, please explain: ________________________________________________________________________________________
Alternate Contacts:
Last Name:
Phone Numbers:
First Name:
Home:
Last Name:
Phone Numbers:
Work:
First Name:
Home:
Work:
Relationship:
Cell:
Relationship:
Cell:
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.
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. Proof of address
4. Face-to-face interview is required to complete application process.
Income means gross cash income and includes earned income, military income (including pay and allowances),
veteran’s benefits, SSI (Supplemental Security Income), SSA - 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
************************************************************************************************************************************************************************************
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 and
Medicaid eligibility. ***
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
_________________________________________
______/______/______
Parent/Guardian Signature
Date
_________________________________________
______/______/______
Signature of person completing this form
(Other than parent)
Date
OFFICE USE ONLY
IDENTITY VERIFICATION
City/County/Country of Birth
State
Other Form of Proof
Birth Date
Birth Certificate Number
Date Documentation Viewed
Date Issued
Person Viewing Documentation
Child’s Birth Name
Mother’s Name
Father’s Name
Child Find/Single Point Entry Referral
Fredericksburg
King George
Application Entered by:
By Whom:
Application Reviewed by:
Income Reviewed:
Income:
Date
Data Entered (child Plus)
Date Reviewed
Face-to-Face Interview
Date Reviewed