Scott County School System’s
2015-16 PreSchool Initiative
Enrollment Criteria:
1. Each child must be 4 years old by September 30 and not served by Head Start.
2. Parents must either live, work, or own property/land in Scott County.
3. The students will need to participate in a diagnostic test to determine greatest
need.
Partial applications will not be accepted. Any application received after April 15th will be held until
late July. We will contact the late applicants before Aug. 1 to schedule a screener, if slots are
available.
Application Window : April 1 – April 15
1. In an envelope, enclose ALL the following: (do not fold) Keep in mind there is not a place set up to complete
paperwork at our office.




Complete PreK Application
Copy of certified birth certificate (not what is issued at hospital & labeled mother’s copy)
Parent or guardian’s proof of Scott County residence (a lease, deed, or property tax receipt) or
proof of employment in Scott County (letter from employer or check stub)
Free/Reduced Lunch Application (for VPI income reporting data purposes only!!!) It will NOT be
processed through the F/R process.
2. Mail or drop off completed application by April 15
th.
There is not a place to complete paperwork at our office.
Scott County Public Schools
VPI Program
340 East Jackson Street
Gate City, VA 24251
3. On the application, you must include information so we can contact you to schedule the PreK Screener
Assessment. In order to be considered for enrollment, the child must participate. This 30 minute
assessment will occur on April 20th at Duffield Primary and Scott County Career & Technical School. No
slot will be held for a student who can’t participate in the screener.
4. Wait patiently for your letter of acceptance. Phone calls will not expedite the process. All letters will be mailed
out April 30th to the address listed under the child.
Operational Details:
Each full time program will follow the Scott County School System calendar. Transportation
will be provided to students. The maximum class size will be 18 students. The curriculum will
follow Virginia’s Foundation Blocks for Early Learning, which establishes a measurable range
of skills and knowledge essential for four-year olds to be successful in kindergarten.
1
Scott County Public Schools
PreK and Virginia PreSchool Initiative 2015-16
Child Information: first
middle
last
Name: _______________________________________________ Nickname: _______________ Date of Birth: ____/_____/_____
Primary Address: _____________________________________ City: _________________ State: ____________ Zip: ___________
Has your child attended Head Start?
yes
no
male
female
List any preschool or child care provider your child has attended: _____________________________________________________
Does your child have insurance?
yes
no If yes, name of insurance: ________________________________________
If your child does not live in Scott County, do you own property or land in Scott?
yes
no
Address of Property: _________________________________________________________________________________________
Does your child have health problems, or chronic conditions we should be aware of? If so, what are your concerns: ____________
___________________________________________________________________________________________________________
Does your child have special needs we should be aware of such as:
Developmental Delay
Speech/Language Disorders
ODD, OCD, ADHD, ADD
Autism
Traumatic Brain Injury
Visual Impairment
Hearing Impairment
Physical Limitations
Mother/Guardian Information:
Name: _________________________________________ Date of Birth: ____/_____/______ lives with child:
yes
no
Address: ___________________________________________ City: _________________ State: ____________ Zip: ____________
Level of Education:
No Diploma/GED
High School Diploma/GED
Some College
College Graduate
Employer: _________________________________________ Hours/Week: _______ Work #: ______________________________
Address of Employer: _________________________________________________________________________________________
Cell #: _____________________________________________ Home#: _________________________________________________
Email address: _________________________________@_______________________________
Father/Guardian Information:
Name: _________________________________________ Date of Birth: ____/_____/______ lives with child:
yes
no
Address: ___________________________________________ City: _________________ State: ____________ Zip: ____________
Level of Education:
No Diploma/GED
High School Diploma/GED
Some College
College Graduate
Employer: _________________________________________ Hours/Week: _______ Work #: ______________________________
Address of Employer: _________________________________________________________________________________________
Cell #: _____________________________________________ Home#: _________________________________________________
Email address: _________________________________@_______________________________
2
Household Information:
List others living in household besides those listed on page 1:
Name:
Relationship to Child:
Date of Birth:
School Attending (if applicable)
_____________________________
_____________________
_____/_____/______
____________________
_____________________________
_____________________
_____/_____/______
____________________
_____________________________
_____________________
_____/_____/______
____________________
_____________________________
_____________________
_____/_____/______
____________________
TOTAL Number of Household Members: ____________
Total Annual Income: $___________________________
Do you have special circumstances that you need to share with us? ____________________________________________________
___________________________________________________________________________________________________________
Do you receive housing assistance?
yes
no
Do any of the following apply to any of the members of your household?
Homeless
FAMIS
Food Stamps/WIC
SSI
School Drop Out
Incarcerated
Single Parent Household
Custody Orders
English as a Second Language
Migrant
Refugee
Place a number (1,2,3) in order of preferred site location for your child:
_______
DUFFIELD PRIMARY
_______
HILTON ELEMENTARY
_______
NICKELSVILLE ELEMENTARY
_______
SHOEMAKER ELEMENTARY
_______
WEBER CITY ELEMENTARY
The child must participate in a screener to determine greatest academic need. Name of person to be contacted to schedule this
appointment? ___________________ Phone number: ___________________________ Best time to call: _________________
Parent/Guardian Signature: __________________________________________________ Date: ___________________________
3
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receives SNAP or TANF benefits, list the
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Name:
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you afe
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the household who âÞ nolfosier ch¡ldren, complête Part
16
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2
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AND RACIAL IDENTIIIES: You are noi required
answer
Rac¡al ldentities: Choose one or m0re ofttìe f0llowino racial identibes (in addition to etìnicity):
Part7.
SIGNAIURE & SOCIAL SECURITY NUMBER:
0ne
E
American lndiaf,/Alaskâ
An ¡dult musl sign the applic¡tion and prcvide lhe fåst loûr digils Dl the Soci¿l
I give I undersland
¿ppiicaliohishueandth¿tallincomeisrcpoded l!ndcßtancithallheschoolwillgctFedcralfunCsbascdonthehformalion
XXX.XX
I Do Not Have
of Social
Number
Native E Asìan E
schoùl offìcials may veriry
Hispanic or Latino
Nôt Hìspanic or Latino
Black 0rAfrlcan American
Native Hawaiian or Other Pacifrc lslander
!
A Social Security Number
of Adult Household Member
Code:
EApprcved Fæ
EDenied Reason:
oùer
Redwed
Elncome
læ
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High
o:
to
lncomplete AppÍcation
$
E
White
they do not have ore, betore lhe applicafion can be approved (ræ Pdvaq Acl Slatemenl on back) PENALTIES FOR MISREPRESENTAION:
theinlomatbn, lundcrslandlfutflpuÞosclygivcfalseinform3¡on,mychildrcnmayloscmâlbcncfitsândìmãybcprosecutcd
ofAdult
_
Notiæ Sent To Household:
Ahourt/How Often
$ 250.00 /M
Signature of Apprcving Off¡c¡al:
I ædiry thaL ôll lnrbrmatio¡ on thir