HENRY COUNTY PUBLIC SCHOOLS



HENRY COUNTY SCHOOLS

PRESCHOOL PROGRAMS

Application

2009-2010 School Year

School

Child’s Name

To the best of my knowledge, the information on this form is correct.

I give Henry County Schools permission to screen my child.

Signature of Parent/Guardian Date

Will the parent(s) need a translator in order to complete the screening interview?

___ yes, specify language: ____________________ ____ no

If a parent is hearing impaired, will an interpreter be needed in order to complete the

screening interview?

___ yes ____ no

Students will not be considered for placement until the application is complete. A complete application must include verification of:

( Birth Certificate ( Social Security # ( Henry County Residency ( Income

( Special Services ( Immunizations

The Henry County School Board does not unlawfully discriminate on the basis of age, sex, race, color, religion, disability, or national origin in its employment practices or educational programs and activities. Mrs. Rebecca Wells, Director of Special Education, is designated as the coordinator for non-discrimination for access to and implementation of programs under Section 504 and the American with Disabilities Act. Mrs. Rebecca Kamguia, Title IX Compliance Officer, is designated as coordinator for non-discrimination regarding personnel matters under Section 504, the American with Disabilities Act and Title IX. Specific complaints of alleged discrimination under Title VI of the Civil Rights Act should be referred to Mrs. Amy Scott, Student Services Specialist.

Child’s Name: Last First Middle

(as shown on birth certificate)

Date of Birth: Place of Birth: Sex: ___Male ___Female

What is the primary language spoken in your child’s home?

Parent/Legal Guardian:

Home Phone Number: Emergency Phone Number:

Are you a resident of Henry County? Yes No

The name of the landmark nearest my home is:

(store, church, public building, etc.)

Has your child previously attended a preschool / daycare program?

Yes (Name of program: )

No

Marital Status: Married Separated Divorced Single

If parents are divorced, who has legal custody of child? Who does the child live with?

Number of Adults in Household: Number of Dependent Children in Household:

Mother’s Name: Date of Birth:

Residential Address:

Mailing Address:

Place of Employment:

Work Phone: Work Hours:

Gross Pay: per week per month per year

Father’s Name: Date of Birth:

Residential Address:

Mailing Address:

Place of Employment:

Work Phone: Work Hours:

Gross Pay: per week per month per year

Legal Guardian/Foster Parent’s Name: Date of Birth:

Residential Address:

Mailing Address:

Place of Employment:

Work Phone: Work Hours:

Gross Pay: per week per month per year

EDUCATION: (Circle the highest grade completed) College Level (Circle one)

Mother 1 2 3 4 5 6 7 8 9 10 11 12 GED 1 2 3 4 Advanced Degree

Father 1 2 3 4 5 6 7 8 9 10 11 12 GED 1 2 3 4 Advanced Degree

Guardian 1 2 3 4 5 6 7 8 9 10 11 12 GED 1 2 3 4 Advanced Degree

Do you receive any of the following services? (Must provide proof of services.)

Food Stamps Yes No Caseworker:

Caseworker’s Phone Number:

Medicaid / FAMIS Yes No

TANF Yes No

SSI Yes No

(supplemental for disability)

Veterans Benefits Yes No

Unemployment Yes No

Social Security Yes No

Name Age Date of Birth School Attending

1.

2.

3.

4.

(Must list and give income of other adults living in the household)

Name Income

Gross Pay: per month per week

Gross Pay: per month per week

Gross Pay: per month per week

Gross Pay: per month per week

per month per week

(TO BE COMPLETED BY HENRY COUNTY SCHOOLS PERSONNEL AT THE TIME CHILD IS SCREENED.)

Verification of Birth Certificate # ___________________________

Verification of Social Security # ___________________________

Verification of proof of services ___________________________

Verification of Henry County residency

Verification of proof of income

Verification of immunizations

Comments:

-----------------------

Preschool Office Use Only

Date of Completed Application (includes verification):

Assigned Screening Date / Time:

FAMILY UNIT

Child Support

STUDENT INFORMATION

CHILDREN LIVING IN HOUSEHOLD

ADULT DATA

Parents/Guardians: Do not complete this section

Henry County offers three preschool programs:

• Virginia Preschool Initiative

• Early Childhood Special Education Preschool Program (ECSE)

• Partners Preschool Program

I understand that placement recommendations will be determined by the Preschool Screening Committee based on verification of application information, personal interview and screening data.

Signature of Parent/Guardian

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