APPLICATION FORM

School Year 2016-17 Roanoke City Preschool Programs A collaboration between Roanoke City Public Schools and TAP Head

Applications are accepted year-round. Initial application review for Head Start is February to May for the 2016-17 school year. Initial application review for RCPS is February 1 – April 15 for 2016-17 school year. Educational home visits are a part of these programs. Information will be handled confidentially. Please complete front and back of this form.

Child’s Information

Child’s Name
Middle: Last:
Male Female
    City:   Zip:
Do you plan to move prior to the first day of school? Yes No Maybe

Age: Primary Language:


Telephone Numbers:
Parent 1 Cell: Parent 2 Cell:
Parent/Guardian 1 Work Phone Total Hours per Week:
Parent/Guardian 2 Work Phone Total Hours per Week:

Current Preschool or Child Care Center (if enrolled):
Is your child toilet trained? Yes No (Toilet training is not a requirement for program acceptance.)
Does your child have a disability or special need? Yes No
If yes, where does your child receive services?
(All programs accept children with disabilities or special needs. Children may be referred to the Roanoke City Schools REACH program.)

Do you have concerns about your child’s development or behavior? Yes No
If yes, please describe your concerns:

Program Selection

There are limited spaces available in all programs. Please consider my child for the following program.
Check one:

Roanoke City Public Schools preschool programs for 4 year olds (full-day hours, same as in elementary schools)
Head Start full day services for 3 and 4 year olds (6:30 am to 6:00 pm available all year, 8:00 am to 4:00 pm is free)
Head Start part-day services for 3 and 4 year olds (4 1/2 hours daily during the school year)

If your child is not eligible for the program you selected, do you wish to be considered for another program listed? Yes No
Do you need transportation for your child to attend? Yes No Unsure
Will you obtain child care before/after the preschool program your child attends? Yes No Unsure
If yes, please list name and location:

The following are required for Head Start enrollment:
*Birth Certificate or Birth Letter     *Current Physical Examination     *Current Immunization Record
For Roanoke City Public Schools Only:
Transportation is provided to/from your child's home address or child care address within your child's home school attendance zone only. Transportation is NOT provided for children who submit transfer requests outside their home school zone. All school bus changes must be submitted to the preschool office no later than JULY 8,2016.
The following documents are required for school entrance by JUNE 10,2016:
*Birth Certificate     *Current Physical Examination     * Current Immunization Record     * Proof of Residency     * Social Security Number

Family Factors

The information on this form is used to determine eligibility and to address family needs.
TAP Head Start and Roanoke City Public Schools do not discriminate on the basis of race,
color, national origin, sex, disability, or age in its programs and activities.

Household Information


    Relationship to child:

Child lives with:
One parent Two parents Foster parents Other/Guardian
)

Brothers and sisters in household under 18 years of age
Full Name: Age: School/Preschool/Child Care Center:
Full Name: Age: School/Preschool/Child Care Center:
Full Name: Age: School/Preschool/Child Care Center:
Full Name: Age: School/Preschool/Child Care Center:

Please provide parents’ annual income: (Documentation required; may include: 2015 W-2, 2015 tax return, most recent pay stubs, current TANF or SSI statement, current SNAP benefits letter with monthly income )

Family Factors: Please check all that apply:

Child is receiving Medicaid/FAMIS
Child has no heath insurance
Family receives TANF-Temporary Assistance for Needy Families (documentation required)
Child has a diagnosed disability
Child has chronic illness (such as diabetes, asthma, etc.)
Child was born prematurely/high risk pregnancy
Child is in foster care
Child was in foster care
Child was in an orphanage
Child or family is in counseling
Teen mother or father at child’s birth
Homeless family (living in/with: street, car, shelter, hotel, friends/relatives)
Incarcerated parent(s)
Deceased parent
Single parent family
Parent deployed in military
Parent has a diagnosed disability
Parent has a mental illness
Chronic or terminal illness in family
Substance abuse in the household
Domestic violence in the home
Family uses English as a second language
Parent/Guardian did not complete high school or receive a GED
Current unemployment
Recent underemployment

Is there anything else you would like us to know about your child or family?

I have reviewed this information and certify that everything above is correct, to the best of my knowledge. I understand that Roanoke City Public Schools and TAP Head Start work in partnership. I give permission for the release of information regarding my child’s screening, eligibility, and enrollment between Roanoke City Public Schools and TAP Head Start. Information will be handled confidentially.

Signature of parent/guardian: (please type your name)
Today's date:

PLEASE NOTE: You must press the "Submit" button above for us to receive this form. You will receive confirmation on the next screen that you can print for your records.