Mixed Delivery Application

Mixed Delivery Application

Please see the Mixed Delivery Funding Eligibility sheet to determine if your family may be eligible. Mixed Delivery slots are awarded on a first come, first serve basis. Please contact Sherry Custis at 757-825-6200 if you have any questions.
Child's Full Name

First Name Middle Name Last Name
Child's Birth Date

Month Day Year
Family's Current Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is this child in foster care or temporarily housed outside of the primary family home?
Is this child homeless?
Definition for homelessness is provided on Project-Hope for Virginia’s website (authorized under the federal McKinney-Vento Homeless Education Assistance Act) https://education.wm.edu/centers/hope/homeless/index.php
Email Address
example@example.com
Phone Number
Primary Parent or Guardian's Information

First Name Last Name
Primary Parent or Guardian's Highest Level of Education
Secondary Parent or Guardian's Information

First Name Last Name
Secondary Parent's Highest Level of Education

Family Income Information

	Family Member's First Name	Annual Salary	Description (Employment, SSI, Child Support)
Primary Adult
Secondary Adult
Additional Family Income
Additional Family Income

Total family income equals
Total Number of Children in Household
All children, including applicant, that reside at the primary residence.
Total Number of Adults in Household
All adults, including primary and secondary adults listed in the application, that reside at the primary residence.
Please select all that apply

This child has suffered abuse or trauma as documented by a professional such as a social services caseworker or psychologist. The child resides in a single-parent home This child is an ELL (English Language Learner) and lives in a home where English is not the primary language The child is raised by persons other than parents This child has a documented disability, such as speech delay This child has a parent that is incarcerated This child has a parent that is or will be deployed within the next 90 days
I certify that all of the above information is true and correct and that all income is reported. I understand that Peake Childhood Center will receive state funds based on the information I give. I understand that deliberate misrepresentation of any of this information may disqualify my child from being considered for this childcare program. I understand that all reported income will be verified with W-2 tax forms and recent paycheck stubs and this application is considered incomplete until income or other qualifying factors are verified.

Yes
Should be Empty: