2014-2015 NC Pre-K Application for Guilford County 1st Choice 2nd Choice 3rd Choice Date of Application: CHILD’S INFORMATION Child’s name First Middle Date of Birth Last If child is not 4, will your child be 4 on or before August 31st? YES Age: Child’s Address Mailing Address If different from above Street City State Zip Street City State Zip American Indian or Alaskan Native Native Hawaiin or Other Pacific Islander Gender Male NO Female Asian Hispanic/Latino Child’s Primary Language County Black or African American White or European American Language spoken at home FAMILY INFORMATION Who does the child live with? Mother and Father Grandparent(s) Single Mother Foster parent(s) Single Father Legal Guardian Mother/Stepmother/Guardian Name Home Phone Number Resides w/ child YES _ Cell Phone What is the child’s family size? Resides w/ child YES _ Cell Phone 2. 3. 4. 5. 6. 7. 8. 9. 10. NO Work Phone Total Number (including the NC Pre-K Child) Please list the names of ALL family members that live in the household. 1. NO Work Phone Father/Stepfather/Guardian Name Home Phone Number Parent & Step parent Other Relationship to the NC Pre-K Child (e.g. mother, father, grandparent, sister, brother, aunt, uncle, stepparent) Age _ Family Income NOTE: Documentation of each applicable source of family’s income is required. Mother/Stepmother/Guardian’s Name: Please check all that apply: Employed: (If employed, please list average hours worked per week): Seeking Employment: Attending secondary education: Attending job training: Current Wages BEFORE Taxes $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Alimony $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Child Support $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Workers' Comp $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Unemployment $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly SSI/TANF/Work First $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Father/Stepfather/Guardian’s Name: Please check all that apply: Employed: (If employed, please list average hours worked per week): Seeking Employment: Attending secondary education: Attending job training: Current Wages BEFORE Taxes $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Alimony $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Child Support $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Workers' Comp $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly Unemployment $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly SSI/TANF/Work First $ This amount is  yearly  monthly  twice monthly  bi-weekly  weekly *If you are currently unemployed, and are not receiving unemployment benefits or other source of regular income please list the person or source that provides support for this family: Amount provided $ week/month I certify this is information is true. If any part is false, I understand my child’s participation in the program may be terminated. Parent/Guardian Signature • • • • Date Other Information Does the parent/legal guardian serve as an active member of the armed forces of the United States? Has a parent been seriously injured or killed while in active duty? Since birth, has this child ever been enrolled in a preschool, child care center, or home day care? Is child currently enrolled in a preschool, child care center, or home day care? If currently enrolled, what is the name of the program? YES YES YES YES NO NO NO NO • • • • Is your child receiving subsidy for child care? YES NO If no, on the subsidy wait list? Has your child been diagnosed with a Special Need? If yes, does child have Individualized Education Plan (IEP)? Does your child have or has he/she ever had a chronic health condition? If yes, what is the health condition? YES YES YES YES NO NO NO NO • Is your child currently or has he/she ever received services for a special need or disability? YES NO If yes, please specify (check all that applies) Speech Physical Therapy Identified disability-Please specify Educational Services Mental Health Other- Please specify PARENT RESPONSIBILITY AND PARTICIPATION I understand this is an application for services offered and does not constitute enrollment into any program. I certify that the information given on this application is true and accurate and all income has been reported. I understand this information is being given for receipt of federal and/or state funds. Program staff may verify the information on this application. Deliberate misrepresentation of the information may subject me to prosecution under applicable federal and/or state laws. The information on this form may be used only in the determination of eligibility for the NC Pre-K program. I hereby release the information so that my child may be considered for the program. The designated agencies may share and/or verify any and all information regarding my child. I understand that if my child is selected to participate in the NCPK program, parent involvement will be critical to the success of my child andI/we commit to participate as required by the program criteria. I understand that NC Pre-K is designed to serve at-risk children and that every effort shall be made by me and the NC Pre-K program to maintain my child’s enrollment and participation. I understand I am responsible for providing transportation for my child if transportation is not available at my child’s school. No application will be considered complete until the following information has been received. Completed Application Birth Certificate Proof of income (1040, W2, Child Support, SSI, SSA, Unemployment Benefits, Workers Comp, Public Assistance/ Work First Benefits, or 3 consecutive paystubs). Proof of Residency (current utility bill or rental agreement) Once a child is accepted in the program the following will need to be submitted to the site your child is placed in: Child’s Immunization Record Individualized Education Plan (IEP) if applicable Health Assessment completed by physician within 30 days of enrollment Parent/Guardian Signature:* Date: Relationship to child: ____________________________* If guardian signs, please attach documentation of guardianship. Request for E-mail address: If you are willing to be contacted via email, please provide your email address below. ____________________________________@____________________________._________ Return completed applications to: Guilford County Partnership for Children 122 N. Elm Street, Suite 1010 Greensboro, NC 27401 CONTRACT ADMINISTRATOR USE ONLY Received by: _________________________ Date Received: ____________________ Date Processed: _____________________