ANDERSON COUNTY PRESCHOOL/HEAD START PROGRAM
ANDERSON COUNTY SCHOOLS’ PRESCHOOL APPLICATION
708 North Main Street
Clinton, Tennessee 37716
Phone: (865) 463-2833 Fax: (865) 463-8876
______________________________________________________________________________
Dear Parent/Guardian,
Thank you for applying to Anderson County Schools’ Preschool. The following required documents must be submitted before we can process your application:
□ Proof of income for a 12 month period (Tax Return, W2’s, Check Stubs, Social Security, SSI, TANF/Families First, Child Support, etc.)
□ Up-to-date Physical
□ Immunization Record
□ Dental Exam
□ Birth Certificate (certified copy)
□ Social Security Card
□ Lead Levels/Hematocrit-Hemoglobin Levels
□ TN Care Card (if applicable)
□ Custody Papers (if applicable)
□ Copy of Driver’s License
□ Proof of Residency
You will be notified the status of your application once it is processed.
• Income eligible children are placed before any over-income children are selected.
• A selection criteria based on need is used to make the final decision on which children will be selected.
• Parents/guardians are responsible for transportation to and from the center.
Local Transportation Services: ETHRA, Uber, Lyft
• Regular attendance is a requirement.
The Preschool Program does not discriminate against employees or clients because of race, color, religion, sex, language, national origin or handicapping condition.
|Center Preference: |Primary Phone: |
| Last First Middle |
|Child’s Name: |
| | |Gender: |
|Birthdate: |Social Security #: |Male Female |
|Child’s Birth City: Birth County: Birth State: Birth Country: |
|Mother’s Maiden Name: |
|Primary Language: |
|Race: Asian Black or African American White Native American Bi-Racial Hispanic |
|Pacific Islander/Hawaiian Other: ________________________________________ |
ANDERSON COUNTY SCHOOLS’ PRESCHOOL PROGRAM
INFORMATION ON HEAD OF HOUSEHOLD
| Last First Middle |
|Primary Adult Name: |
| |Marital Status: |Gender: |Relationship to applicant: |
| |Single Married |Male Female | |
|Birthdate: |Divorced Separated | | |
| |Widowed | | |
|Last grade in school: ________________ Diploma GED Some College/Training (no degree/certificate) |
|Some College/Training (certificate) Associate’s Degree |
|Bachelor’s Degree Master’s Degree |
|Place of Employment: _______________________ |Work Phone: |Cell Phone: ___________________ |
|Occupation: _______________________ | |Can you receive text messages? |
| | |Yes No |
|Race: Asian Black or African American White Native American Bi-Racial Hispanic |
|Pacific Islander/Hawaiian Other: ________________________________________ |
|Living Address: |
|Apt. No# Street City Zip Code County |
|Mailing Address: (if different from above) |
|Apt. # Street City Zip Code County |
|Do you have internet at home? Yes No Email Address: |
| Last First Middle |
|Secondary Adult Name: |
|(If living in the home) |
| |Marital Status: |Gender: |Relationship to applicant: |
|Birthdate: |Single Married |Male Female | |
| |Divorced Separated | | |
| |Widowed | | |
|Last grade in school: ________________ Diploma GED Some College/Training (no degree/certificate) |
|Some College/Training (certificate) Associate’s Degree |
|Bachelor’s Degree Master’s Degree |
|Place of Employment: ______________________ |Work Phone: |Cell Phone: _________________ |
|Occupation: ______________________ |____________________ |Can you receive text messages? |
| | |Yes No |
|Race: Asian Black or African American White Native American Bi-Racial Hispanic |
|Pacific Islander/Hawaiian Other: ________________________________________ |
|Living Address: |
|Apt. No# Street City Zip Code County |
|Mailing Address: (if different from above) |
|Apt. # Street City Zip Code County |
|Do you have internet at home? Yes No Email Address: |
LIST CHILD’S SIBLINGS WHO LIVE IN HOUSEHOLD
Name Sex Birthdate Name of School Grade
| | | | | |
| | | | | |
| | | | | |
| | | | | |
EMERGENCY/PICK UP/RELEASE INFORMATION
Please list at least 3 names and phone numbers of person to notify in case of an emergency:
(E = Emergency Pick up ONLY I = Information can be release)
| | | | | |
| | | | | |
| | | | | |
Name (order of importance) Relationship to Child Home/Cell Phone E I
DO NOT RELEASE MY CHILD TO:
Papers on file?
Do Not Release My Child To: Relationship to Child: Yes No
| | | | |
| | | | |
| | | | |
****Must have custody papers on file, parenting plan, restraining order, etc. to restrict a birth parent from picking up a child if they are on the application or the child’s birth certificate.
Family Composition and Resources
Child’s Name: ________________________
Number of adults in family: ______ Number of children in family: ______
Type of services or financial assistance received (Mark all that apply)
□ Medical financial assistance (i.e. Tenn Care/Medicare)
□ Food Stamps
□ Public Assistance/Welfare (i.e. TANF/AFDC)
□ Child Care Assistance
□ WIC
□ Supplemental Security Income (SSI)
□ Foster Care/Adoption subsidy
□ Unemployment insurance
□ Public housing assistance
□ Energy program assistance
□ Child support/alimony
□ Other: specify ________________________
If family is receiving Public Assistance, answer the following:
Began receiving services ______/______/_____
Family applied to receive Supplemental Security Income (SSI) ( Yes ( No
EMPLOYMENT FAMILY TYPE
| | |
|Employed full-time |2 parents, both working |
|Employed Part-time |2 parents, one working |
|Seasonally Employed |2 parents, neither working |
|Unemployed |Single father, working |
|Retired |Single father, non-working |
|Fully Disabled; Disability |Single mother, working |
|In Families First |Single mother, non-working |
|In Other Training |Other relative, working |
|In School/College/GED Classes |Other relative, non-working |
|(Circle One) |Foster parent |
|In High School | |
|Name of School Attending:___________ | |
|_______________________________________ | |
Anderson County Schools’ Preschool is responsible for maintaining confidentiality and protecting the privacy of personal identifiable information about children and families. Parents of children enrolled have the right to review child and family records and request explanation of information in these records.
Miscellaneous Information
Child’s Name: _________________________
Check any of the following events which have occurred in your immediate family during the past two years:
□ Death of a Spouse Military Service
□ Substance Abuse Jail Term
□ Marriage Domestic Violence
□ Divorce Personal Injury
□ Marital Separation Birth
□ Job Loss Serious Illness
□ Retirement Family Move
□ House Fire
1. Death of a close family member? Yes No
2. Has family been homeless in last 12 months? Yes No
(Family is considered homeless if living in car, shelter, motel, campground, been evicted from housing, etc.)
3. Does any family member have a disability or handicapped condition?
□ Yes (if so, whom?): ____________________________________
□ No
4. How did you learn about our program?
□ Newspaper/Radio
□ Preschool Round-Up
□ Prior Family
□ Word of Mouth
□ Elementary School
□ Child Find
□ TEIS
□ Referred
□ Community Event
□ Community Agency
□ Flyers
□ Friend
□ Walk-In
□ Pharmacy Bags-Food City
□ Post Card
□ Social Media
□ Internet/ACS Website
□ Other (Please Specify)______________
5. Are you enrolled in Healthy Start? Yes No
6. Were you an essential worker during the COVID-19 pandemic? Yes No
7. Are you learning another language in addition to your primary language?
□ Yes (what language?): ___________________________________
□ No
Medical/Health Information
Child’s Name: ________________________
Physical Exams are required. You should request that it be recorded on the Tennessee State School Physical Form for Preschool. Be sure the Doctor or Health Department does a physical examination that meets EPSDT requirements.
NOTE: Be sure the Doctor or Health Department documents the results of the examination and all tests!
Child's Doctor:_______________________________
Phone Number:_______________________________
Doctor's address:______________________________
Date of Last Physical:__________________________
Child's Dentist:_______________________________
Phone Number:_______________________________
Dentist's address:______________________________
Date of Last Visit:_____________________________
• Does your child have health insurance?
□ Yes, my child has private insurance.
□ Yes, my child has TN Care.
□ No, my child does not have insurance.
Does your child have dental insurance?
□ Yes, my child has private dental insurance.
□ Yes, my child has TN Care.
□ No, my child does not have dental insurance.
Do parents have medical insurance?
□ Yes, parents have private insurance
□ Yes, parents have TN Care
□ No, parents do not have insurance
• Do parents have dental insurance?
□ Yes, parents have private dental insurance
□ Yes, parents have TN care
□ No, parent do not have dental insurance
1. Does your child have any allergies?
□ Yes, my child is allergic to: ____________________________________
If yes, which doctor checked your child for allergies?: ________________
□ No, my child does not have allergies.
2. Does your child have any medical conditions that we should know about?
□ Yes (please explain): __________________________________________
□ No, my child does not have any medical conditions.
3. Has your child ever been to a medical specialist (i.e. neurologist, psychologist, speech and language pathologist, ENT, audiologist)?
□ Yes, (name specialist): ________________________________________
□ No, my child has not been to a medical specialist.
(Medical/Health Information Continued)
4. Does your child take medication regularly?
□ Yes, my child takes medication regularly
If yes, list medications and how often taken:____________________________
□ No, my child does not take medication.
5. Is your child on a special diet?
□ Yes, (please explain): _________________________________________
□ No, my child is not on a special diet.
6. Does anyone have concerns about your child’s overall health, development, or speech?
□ Yes, (please describe concerns): _________________________________
□ No, no one has concerns.
7. Have you ever received services from TEIS?
□ Yes (what services did you receive?): _____________________________
□ No
8. Does your child currently have or have they ever had, an IEP or IFSP?
□ Yes (please explain): __________________________________________
□ No
9. Is your child suspected of experiencing developmental delay:
□ Yes, (by whom?): _____________________________________________
□ No
10. If you answered yes to the previous question, has an evaluation completed?
□ Yes. Diagnosis?: ___________________________________________
□ No
11. Type of Impairment or Disability: ______________________________________
12. Type of services received for disability? _________________________________
13. Does your child have any difficulty seeing?
□ Yes
□ No
14. Does your child wear Glasses?
□ Yes
□ No
15. Please let us know if there is anything else you think we should know in regards to your child’s medical health: _______________________________________________________________
_______________________________________________________________
Health and Nutrition Information
1) Was your child considered premature at birth? (less than 32 weeks)
□ Yes, (how many weeks?): __________________________________
□ No
2) We provide Parents Choice diapers. Should your child need a specific brand due to sensitivity, we must have a doctor’s note on file.
□ Parent’s Choice, Size: ______________________________________
□ Specific Brand, Size: ______________________________________
(Please attach doctor’s note)
3) We provide formula, please provide us with the name of the brand that you prefer we use for your child: _______________________________________________
4) We provide bottles, please provide us with the name of the brand that you prefer we use for your child: _______________________________________________
5) Please let us know if there is anything else you think we should know in regards to your child’s nutritional needs: _______________________________________________________________
_______________________________________________________________
Thank you for completing our application. Please remember that this application CANNOT be processed until it is ENTIRELY complete.
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Before turning in this application, did you attach the follow required documents?
□ Proof of income for a 12 month period (Tax Return, W2’s, Check Stubs, Social Security, SSI, TANF/Families First, Child Support, etc.)
□ Up-to-date Physical
□ Immunization Record
□ Dental Exam
□ Birth Certificate (certified copy)
□ Social Security Card
□ Lead Levels/Hematocrit-Hemoglobin Levels
□ TN Care Card (if applicable)
□ Custody Papers (if applicable)
□ Copy of Driver’s License
□ Proof of Residency
Parent/Guardian Signature Date
-----------------------
DO NOT RELEASE MY CHILD TO: (CUSTODY PAPERS REQUIRED IF APPLICABLE)
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