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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