Richmond Public Schools



Richmond Public Schools

CRITERIA CHECKLIST FOR PRESCHOOL PROGRAMS Revised 2011

The following checklist may be used in the identification of children for Preschool Programs. Please check all items that are applicable to the applicant. Parent or guardian must sign this document for the application to be considered

|INCOME – Check all that apply |ENVIRONMENT – Check all that apply |

| | |

|( eligible for reduced meals through the USDA guidelines |( resident of a public housing development |

|( eligible for food stamps |( resident of substandard housing and utilities |

|( medical/emergency circumstances reducing net income |( transient/homeless family (Multi-family) |

|( family receives WIC |( family history of special education identification |

|( family receives child care subsidy |( two or more preschoolers live in home |

|( TANF ( VIEW Participate ( SSI | |

|FAMILY INFORMATION – Check all that apply |CHILD LIVES WITH: (Must check one) |

| | | |

|History of: |Child: |( foster care parent(s) |

|( violence or incarceration |( mental health concerns |( teenage parent(s) (currently) |

|( substance abuse |( dental health concerns |( guardian other than parent |

|( child abuse or neglect |( physical health concerns |( single parent |

|( anti-social behavior |( developmental delay concerns |( single parent- employed or in school or job training |

|( truancy |( English as Second Language |( both parents |

|( school drop-outs |( Former EHS/Head Start Child |( both parents - employed or in school or job training |

|( domestic violence |Parent(s): |( Parent(s) - in high school |

|( Other _________________ |( with a disability |Will child ( need/( have before and/or after school care? YES ( |

|______________________ |( incarcerated |NO ( |

| |( English as Second language | |

| PARENT/GUARDIAN OBSERVATIONS OF CHILD– Check all that apply |

|( speech/language deficits ( aggressive behavior ( failure to thrive ( withdrawn behavior ( physical disability |

|Does student have limited English proficient status? |YES |__ |NO |__ |

|Does student have immigrant status? |YES |__ |NO |__ |

|Does student have refugee status? |YES |__ |NO |__ |

|Does the student have migrant status? |YES |__ |NO |__ |

|Does the student have a homeless status? |YES |__ |NO |__ |

|Do you give your child permission to be screened for English Language Proficiency? |YES |__ |NO |__ |

|IF YES, please sign here _______________________________________________ | | | | |

Children with Special Needs: Children will be evaluated in coordination with the school system’s Early Childhood Education Program and placed according to the least restrictive environment. Preschool Program Staff will review all applications and Individualized Educational Plans (IEP) to identify children who have special needs and to ensure appropriate placement of children with special needs. Please check below if items apply to your child.

← Child is currently undergoing evaluation for exceptional education

← Child is currently eligible for exceptional education and has an existing Individualized Educational Plan (IEP) or Individual Family Service Plan (IFSP)

Your signature validates that you have carefully reviewed the information above and all items checked are accurate.

Parent/Guardian ___________Date:____________

Staff __________________Date: ___________

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Child’s Name: _________________________________________________________DOB: _______________

Parent / Guardian Name: _____________________________________________________________________

Street Address: ________________________________________________________ Apt. #: ______________

City: _______________________________State: _______________________ Zip Code: _________________

Home Phone: ___________________Work Phone: ___________________ Email Address ________________

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