NCPK Application 22-23

NC Pre-Kindergarten Program 2022-2023 Application
Date Completed Application Received (For office use only)

Month Day Year
Date
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Child's Gender *

Male Female
Is Your Child a Twin/Triplet? *

Yes No
Child's Ethnicity: Hispanic? *

Yes No
Child' Race: (select all that apply) *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White or European American
NC Resident? *

Yes No
Is The Child a US Citizen? *

Yes No
Child Lives With: Legal/Guardian Custodian (Must provide court order): *

Both Parents Mother Father Foster Care Legal Guardian/Custodian (Must provide court order) Kinship Care (Relative without legal documents) Other
Please select the option that best describes your living situation: *

Permanent Live with Adult Relative Live with Non Relative Hotel/Motel Hospital for 30 Days or Less Battered Women & Children's Shelter Lack Permanent Night Time Address Homeless or Emergency Homeless Shelter
Contact Information
Physical Address (the utility bill must match your physical address) *

Street Address

Street Address Line 2

City

Postal / Zip Code
Mailing Address (if different from physical address)

Street Address

Street Address Line 2

City

Postal / Zip Code
Primary Phone *
Cell Phone
Primary E mail (email required to submit online application) *
example@example.com
Alternate E mail (used for important notifications only)
example@example.com
Emergency Contact (someone other than the parent): *

First Name Last Name
Emergency Contact Phone Number: *
Mother/Stepmother/Guardian Information

If the child does not live with mother/stepmother/guardian please select N/A for the following questions. You may enter N/A for the first & last name.
Mother/Stepmother/Guardian's Name *

First Name Last Name
Relationship to the child: *

Mother Stepmother Guardian/Custodian Relative Non-relative Not Applicable
What is mother/stepmother/guardian's marital status? *

Single Married Divorced Not Applicable Other
If married please include your spouse's name:
What is mother/stepmother/guardian's employment status? (Check all that apply) *

Employed Seeking Employment Attending College In Job Training Attending High School/GED Program Not Applicable Self Employed Other
If mother/stepmother/guardian is employed, what is the frequency of pay? *

Weekly Bi-Weekly (paid every other week) Monthly Semi-Monthly (paid twice per month) Not Applicable Other
Mother's Other Sources of Income

Please enter the amounts received MONTHLY, for all other sources of income.
Child Support Received
SSI (Social Security Income)
Other Income Received (please list amount & source)
Father/Stepfather/Guardian Information

If the child does not live with father/stepfather/guardian please select N/A for the following questions.
Father/Stepfather/Guardian's Name *

First Name Last Name
Relationship to the child: *

Father Stepfather Guardian/Custodian Relative Non-relative Not Applicable
What is father/stepfather/guardian's marital status? *

Single Married Divorced Not Applicable Other
If married please include your spouse's name:
What is father/stepfather/guardian's employment status? (Check all that apply) *

Employed Seeking Employment Attending College In Job Training Attending High School/GED Program Not Applicable Self employed Other
If father/stepfather/guardian is employed, what is the frequency of pay? *

Weekly Bi-Weekly (paid every other week) Monthly Semi-Monthly (paid twice per month) Not Applicable Other
Father's Other Sources of Income

Please enter the amounts received MONTHLY, for all other sources of income.
Child Support Received
SSI (Social Security Income)
Other Income Received (please list amount & source)
List additional children living in the house, under 18 yrs old ONLY:

If the child applicant is an only child, please skip this section.
Child 1: child's name Birthdate: birthdate Relationship to the child applicant:
Child 2: child's name Birthdate: birthdate Relationship to the child applicant:
Child 3: child's name Birthdate: birthdate Relationship to the child applicant:
Child 4: child's name Birthdate: birthdate Relationship to the child applicant:
Use this space to record additional children, under the age of 18, if needed.
Adult 1: adult's name Relationship to the child applicant:
Adult 2: adult's name Relationship to the child applicant:
Adult 3: adult's name Relationship to the child applicant:
Adult 4: adult's name Relationship to the child applicant:
Record additional adult family members in the household, if needed.
Has your child been referred for evaluation for or identified with any developmental needs or disabilities? *

Yes No
If yes date of referral

Month Day Year
Date
Does your child have an IEP or an IFSP? (If yes, please upload a copy) *

Yes No
Is your child currently receiving any specialized services? (if yes, please upload supporting documents)? *

No Yes, please explain:
Do you have any concerns about your child's development? *

No If yes, please explain:
Does your child have any chronic health concerns? (If yes please upload supporting documentation from a physician.) *

No If yes, please explain:
Additional Information About Your Household
Is at least one parent or legal guardian of this child an active-duty member of the military? (If yes, please provide evidence.) *

Yes No
Was a parent or legal guardian of this child seriously injured or killed while on active duty? (If yes, please provide evidence.) *

Yes No
Is your child currently enrolled in a preschool or childcare program? *

No No, but the used to be. Yes, please list the name of the childcare program where your child currently attends.
If your child is currently enrolled in preschool/childcare do you have a DSS voucher or other type of subsidy to pay for the cost of childcare?

Yes No
Is English spoken in the home? *

No English Some English We speak fluent English
Please list all languages are spoken in the home: *
Is there any other information you would like to share with us?
Site Selection

Refer to the FAQ document, on our website, to learn how placement is handled.

Please pick your top 3 choices, for NC Pre-K placement if eligible. *

	1st Choice	2nd Choice	3rd Choice
Select Facility

Smart Start Rowan provides many FREE educational programs as well as family events. Please take a moment to tell us which program/activity you would like more information about. A member of our team will contact soon.

Triple P (Positive Parenting Program) - Assistance with challenging behaviors Kaleidoscope Play & Learn (KPL) - Playgroups Early Learning Resource Center (ELRC) - Book & toy lending library Dolly Parton Imagination Library - Free monthly book delivery Better Together Positive Parenting Rowan Facebook group Family Support – Info about community resources such as Medicaid/insurance options Add Me to Your Email Contact List - Stay informed about upcoming events & programs
Family Information and Responsibilities

Your child’s success in the NC Pre-K program depends on your active participation as well as your compliance with program guidelines. We have identified a few of the most important things below. Please read carefully and check each statement below to acknowledge your understanding & agreement. *

	I Agree
I give permission for my child to receive developmental, hearing, vision, dental and/or speech screenings; and for the results of these screenings to be shared with Smart Start Rowan (SSR), the school where my child is assigned and the exceptional children’s department of the local school system for purposes of my child receiving needed services.
I understand that if my child is selected for participation, family involvement is necessary and expected.
My family will cooperate with the program to submit necessary documentation and forms as requested.
I understand that transportation to and from the NC Pre-K program will be the family’s responsibility. However, some sites may provide a limited amount of transportation for a fee.
I will inform my child’s assigned NC Pre-K program, if there is a change in our family’s address, phone number, or authorized parties that can pick-up my child.
I understand that my child will need a current health and dental assessment as well as immunization records in order to participate in the program. It is my responsibility to submit these to my child’s assigned school before the deadline. The deadline is 30 days after school begins.
I understand that my child may be placed on a waiting list, if all available slots are full.
I understand that if my child has trouble adjusting, I will be asked to participate in parent conferences and actively work with SSR and my child’s assigned NC Pre-K program to develop a plan of action to address these concerns.
I understand that if my child is not in attendance regularly, my child’s NC Pre-K slot will be awarded to another child.
I understand that it is my responsibility to get my child to school on time and pick my child up promptly at dismissal time. I’m aware that I may be charged a late fee, if late pick-up becomes a pattern.
I understand that if my child is accepted into the NC Pre-K program, I must accept placement before the deadline indicated on my child’s acceptance letter. If I do not accept placement my child will be placed on the waiting list, until another slot becomes available.

Financial Uploads - Select all sources of financial support received by your family (include both parent/guardians if applicable). Upload supporting documents for each of the relevant items you selected below:

Employed (1 month's recent pay stubs for everyone employed) Self employed (2021 tax return or 1099) Social Security Income (most recent statement) Supplemental Security Income (most recent statement) Child Support (court order or written statement) Other (supporting documents) Not Employed (complete No Income Verification form)
Upload all relevant financial documents.

Cancel of
Health Documents Upload - Select & upload all relevant health documents that pertain to your child. Items with an *are required for all children.

IEP/IFSP (if applicable) Chronic Health Condition Documentation (if applicable) Developmental Delay Documentation (if applicable)
Health Documents Upload.

Cancel of
Additional Documents Upload - Select and upload all relevant additional documents that pertain to your child. Please note that some items may not apply to your family situation. Items with an * are required for all children..

Parent/Guardian Photo ID* Proof of Residency* Child's Birth Certificate* College/School Schedule (if applicable) Military Status documentation (if applicable) Custody/Guardianship documentation (if applicable)
Additional File Upload - Use the checklist above to upload the required documents.

Cancel of
My signature below is acknowledgement of the following:
- I am the legal parent/guardian of the child applicant.
- All of the information on this application is true to the best of my knowledge.
- I give permission for information regarding my child to be shared between Smart Start Rowan and the school my child may be assigned to and/or the local school system. I understand this information is necessary and will be used for the determination of data analysis, enrollment, eligibility and for educational purposes only.
- I have read and will comply with the Family Information and Responsibilities.
- I acknowledge that the application must be signed & dated, all sections completed, and all required documents must be received before my application will be processed & my child considered for placement.
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Contact Information

Mother/Stepmother/Guardian Information

Mother's Other Sources of Income

Father/Stepfather/Guardian Information

Father's Other Sources of Income

List additional children living in the house, under 18 yrs old ONLY:

Additional Information About Your Household

Site Selection

Family Information and Responsibilities