Application NC Pre-K 26-27

NC Pre-Kindergarten Program Application 2026-2027

To apply, please enter your child's birthdate to determine if your child meets the age eligibility requirements. Must be born between 9-1-2021 and Aug. 31, 2022!
Child's Date of Birth*

MonthDayYear
Date

NC Pre-Kindergarten Program 2026-2027 Application

To apply, please enter your child's birthdate to determine if your child meets the age eligibility requirements. Must be born between 9-1-2021 and Aug. 31, 2022!
Date Application Complete (For Office Use Only)

MonthDayYear
Date
Child's Full Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*

MaleFemale
Is Your Child a Twin/Triplet?*

YesNo
Child's Ethnicity: Hispanic?*

YesNo
Child' Race: (Race refers to a person's physical characteristics, such as bone structure, skin, hair and eye color.) *Select all that apply!*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or European American
NC Resident?*

YesNo
Is The Child a US Citizen?*

YesNo
Child Lives With: (Legal/Guardian Custodian must provide court order):*

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

PermanentLive with Adult RelativeLive with Non-RelativesHotel/MotelHospital for 30 Days or LessBattered Women & Children's ShelterLack Permanent Night Time AddressHomeless or Emergency Homeless Shelter
Contact Information
Physical Address (the utility bill must match your physical address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Cell Phone Number
By providing your cell number you give Smart Start Rowan permission to send you a text.
Primary E mail (Most communication from SSR will be sent via email.)*
example@example.com
Alternate E mail (used for important notifications only)*
example@example.com
Emergency Contact Person: (someone other than the parent/guardian)*
Emergency Contact Phone Number:*
Select all that apply for your family. (Documentation may be required, if your family exceeds income guidelines.)

Experiencing HomelessnessIn Foster CareWICSSIReceiving Refugee ServicesPublic HousingTANF/Work FirstSNAPFood & Nutrition ServicesMedicaidNot Applicable
Primary Parent/Guardian/Caregiver/Custodian Information
Parent/Guardian/Caregiver's Name*

First NameLast Name
Relationship to the child:*

Parent (Biological Mother/Father)Stepmother/StepfatherLegal Guardian/CustodianRelativeNon-RelativeFoster Care/DSS
Type a question*

SingleMarriedDivorcedOther
If married please include your spouse's name:
What is your employment status? (Check all that apply)*

EmployedSelf EmployedSeeking EmploymentAttending CollegeIn Job TrainingNot WorkingAttending High school or GED programOther
If employed, what is the frequency of pay?*

WeeklyBi-Weekly (Every other week)Monthly (Once per month)Semi-Monthly (Twice per month)NotApplicableOther
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)
Secondary Parent/Guardian/Caregiver/Custodian Information

If there are two adults in the household, please complete this section. In a single family household skip these questions.
Secondary Parent/Guardian/Caregiver's Name

First NameLast Name
Relationship to the child:

Parent (Biological Mother/Father)Stepmother/StepfatherLegal Guardian/CustodianRelativeNon-RelativeFoster Care/DSS
Type a question

SingleMarriedDivorcedOther
If married please include your spouse's name:
What is your employment status? (Check all that apply)

EmployedSelf EmployedSeeking EmploymentAttending CollegeIn Job TrainingNot WorkingAttending High school or GED programOther
If employed, what is the frequency of pay?

WeeklyBi-Weekly (Every other week)Monthly (Once per month)Semi-Monthly (Twice per month)NotApplicableOther
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's Name . Child's Birthdate Relationship to child applicant.
Child's Name . Child's Birthdate Relationship to child applicant.
Child's Name . Child's Birthdate Relationship to child applicant.
Child's Name . Child's Birthdate Relationship to child applicant.
Child's Name . Child's Birthdate Relationship to child applicant.
Child's Name . Child's Birthdate Relationship to child applicant.
Use this space to record additional children, under the age of 18, if needed.
List additional adults living in the house.
Adult's Name . Relationship to the child applicant:
Adult's Name . Relationship to the child applicant:
Adult's Name . Relationship to the child applicant:
Adult's Name . Relationship to the child applicant:
Adult's Name . Relationship to the child applicant:
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 or identified with any developmental needs or disabilities?*

YesNo
If yes date of referral

MonthDayYear
Date
Does your child have an IEP? (If yes, please upload a copy)*

NoIf yes, which state issued the IEP?
Is your child currently receiving any specialized services, ex ABA Therapy, Speech etc.? (If yes, please upload supporting documents)*

NoIf yes, please explain.
Do you have any concerns about your child's development?*

NoIf yes, please explain:
Does your child have any chronic health concerns? (If yes please upload supporting documentation from a physician.)*

NoIf 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? (this includes Reserve status) (If yes, please provide evidence.)*

YesNo
Was a parent or legal guardian of this child seriously injured or killed while on active duty? (If yes, please provide evidence.)*

YesNo
Is your child currently enrolled in a preschool or childcare program?*

Child has never been enrolled in preschool/child careChild used to be enrolled, but not currently enrolled.Chils is currently enrolled, please list the name of the childcare program below.
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?*

YesNo
Does the child speak English at home?*

No EnglishSome EnglishFluent 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 the placement is handled. Please keep in mind that site offerings may change based on demand and availability.

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

	1st Choice	2nd Choice	3rd Choice
Service Quality

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 behaviorsKaleidoscope Play & Learn (KPL) - PlaygroupsEarly Learning Resource Center (ELRC) - Book & toy lending libraryDolly Parton Imagination Library - Free monthly book deliveryFamily Support – Info about community resources such as Medicaid/insurance optionsAdd 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.

Document Uploads

Applications will not be processed without the appropriate documents.
Financial Uploads - Please upload supporting documents for each of the relevant items you selected below. (include both parent/guardians if applicable):

Employed Send Most Recent Pay Stubs (ex: Monthly = last pay stub, Bi-weekly = last 2 pay stubs, Weekly = last 4 pay stubs)Self employed (2024/2025 tax return or 1099)Social Security/Supplemental Security Income (most recent statement)Child Support (court order or written statement)Public Assistance Documentation (send qualifying letter only if your family exceeds income guidelines) (ex. Medicaid, Housing Authority etc.)Military or 2nd Job IncomeOther - Complete Non Verifiable Income form (ex. if you are paid in cash or if pay is inconsistent)Not Employed (complete No Income Verification form)
Upload all relevant financial documents.

Cancelof
Health Documents Upload - Select & upload all relevant health documents that pertain to your child.

IEP (if applicable)Chronic Health Condition Documentation (if applicable)Developmental Delay Documentation (if applicable)
Upload all relevant health documents.

Cancelof
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 (utility bill, Letter of Residency Form (in a shelter/live with someone)*Child's Birth Certificate (Can be ordered from Office of Vital Statistics, Mother's Copy from the hospital is sufficient)*College/School Schedule (if applicable) - This must show your name & current enrollmentMilitary Status documentation (if applicable) - ex. Photo ID, Form DD214Custody/Guardianship documentation (if applicable)
Additional File Upload - Use the checklist above to upload the required documents.

Cancelof
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, NC Pre-K sites and/or the local school system(s).
- 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*

MonthDayYear
Date

Thank you for your interest in Smart Start Rowan's NC Pre-K program. We are sorry to inform you that your child does not meet the age eligibility requirements to participate. To be eligible, your child's birth date must be between 9-1-2021 and 8-31-2024. You may want to contact Salisbury Rowan Community Action Agency to apply for the Salisbury/Rowan Head Start program. Their contact info is 704-633-6633 or visit www.srcaa.com. Or, if you reside near Kannapolis you may contact McKnight Head Start at 704-932-7433 or visit https://mck.kcs.k12.nc.us/.
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NC Pre-Kindergarten Program Application 2026-2027

NC Pre-Kindergarten Program 2026-2027 Application

Contact Information

Primary Parent/Guardian/Caregiver/Custodian Information

Other Sources of Income

Secondary Parent/Guardian/Caregiver/Custodian Information

Other Sources of Income

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

List additional adults living in the house.

Additional Information About Your Household

Site Selection

Family Information and Responsibilities

Document Uploads