Giles County Preschool Application Form
Student Name
*
First Name
Middle Name
Last Name
Suffix
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address, if different
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list current and past preschool/childcare programs your child has attended:
*
Parent/Guardian 1's Information
Parent/Guardian's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email address
*
Lives with the child:
*
Yes
No
Education: (Mark highest level achieved)
*
No GED
GED
HIgh School Diploma
Some College
Associate's degree
Bachelor's or above
Employer:
*
*
Full Time
Part Time
Not employed
Are you attending a school or training program?
Attending full time
Attending part time
Not enrolled in a school or training program
Parent/Guardian 2's Information
Parent/Guardian's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email address
*
Lives with the child:
*
Yes
No
Employer:
*
Education: (Mark highest level achieved)
*
No GED
GED
HIgh School Diploma
Some College
Associate's degree
Bachelor's or above
*
Full Time
Part Time
Not employed
Are you attending a school or training program?
Attending full time
Attending part time
Not enrolled in a school or training program
Program Selection
Only one application must be submitted for consideration to all three preschool programs. Please select the programs listed below in order of your preference.
*
First Choice
Second Choice
Third Choice
Not interested
VPI
Giles County Public School's Virginia Preschool Initiative
provides early childhood education for 3- and 4-year olds in the public school with full day school hours; transportation available
Head Start
Head Start preschool provides comprehensive family services and early childhood education for 3- and 4-year olds with full school day hours
Mixed Delivery Preschool
Through United Way Ready Region Southwest, Mixed-delivery provides early childhood education for 3- and 4-year olds with full day hours at Imagination Station
If your child is not accepted into their first choice program, please consider my child for other programs.
Yes
No
Addition Family Information
Please list others in the household, including siblings, who are related by blood, marriage, or adoption. List their names, date of birth, and their relationship to the child. If there are no others, type none.
*
What is your total yearly household income? (All programs require documentation of income for the past 12 months.)
*
$0 to $ 15,000
$16,000 to $25,000
$26,000 to $32,000
$33,000 to $40,000
$41,000 to $50,000
$51,000 to $60,000
$61,000 to $70,000
$71,000 to $80,000
$81,000 and above
Do you receive any of the following? Check all that apply:
*
TANF
SSI
SNAP benefits
Medicaid
None of the above
Has you child been diagnosed with any of the following conditions? Check all that apply:
*
Developmental Delay
Speech or language disorders
ADHD
Autism
Visual impairment
Hearing impairment
Orthopedic impairment or gross motor limitations
None of the above
Other
Does your child currently have an Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP)?
*
Yes
No
Does your child have any health or medical concerns? Check all that apply:
*
Allergies
Asthma
Diabetes
Other diagnosed health condition
Prescribed medication
None of the above
Other
Please check any of the following family factors that your household has experienced in the past year:
*
Homelessness, or having to live with others due to lack of housing
Military Deployment
Incarceration of a family member
Domestic violence, abuse or trauma
Lack of food
Involvement with the Department of Social Services
Substance Use Disorder
Loss of employment
Receiving mental health services
Child is or has been living with someone other than the parent(s)
Child is a foster child
Single parent household
None of the above
Other
What is the primary language in the household? If other languages are spoken please list as well.
*
Are you able to transport your child to a preschool program?
*
Yes
No
How did you hear about the program?
Head Start, Ready Regions of Southwest Virginia, and Giles County Public Schools take into consideration a number of factors in order to determine eligibility, such as household income, the age of child, number in household, and family needs. This information will be considered along with other information shared with our staff during the application process to determine eligibility to best serve your family. By checking below, I authorize the release of all medical, dental, educational, and developmental information to be shared by Head Start, Ready Regions of Southwest Virginia, and Giles County Public Schools. I understand there are limited spaces available in all programs.
I agree
Please type your name as signature with the date.
Submit
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