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CVCA Head Start / Early Head Start / TCPSP Application

Serving Bland, Smyth, Tazewell and Wythe Counties

Dear Families:

Attached you will find an application for PreK (child must be 4 by September 30), Head Start (child must be 3 or 4 by September 30), and Early Head Start (child may be birth to age 3; pregnant women are also eligible). This application serves all three programs. A selection committee will make the determination as to your child’s placement. The selection committee will begin making placements during the first week of July from eligible applications and will continue to place children until all available slots are filled. Parents/guardians will receive
notification of their child’s placement during the first two weeks of August.
No placement decisions will be discussed prior to this time, nor will any child be discussed with anyone other than the child’s parent or legal guardian.

Please remember that your child’s application CANNOT be processed without ALL the 
necessary documents.

These documents include:

• Proof of Income, completion of Homeless Form (with documentation of any household income), or No Income Form Check stubs need to be for the most recent 4 week period prior to completing the application or a W2 or Income Tax Forms may be used. If you receive TANF or SSI please provide documentation.

• Foster Care Documents (if applicable) – proof of income must be included in addition to these documents in order to determine eligibility for Pre K.

• Proof of Birth – Pre K applicants must provide a copy of child’s birth certificate with application; upon enrollment to the Pre K program the original birth certificate must be presented to the school staff member who is enrolling child.  Head Start and Early Head Start may use a birth certificate or a birth letter for enrollment. If you do not have these items and need help obtaining them, please
contact the Tazewell County Pre-School Partnership for assistance.

• Two Items Documenting Physical Address

• If you indicate that you child has a current, diagnosed disability, please provide a copy of his/her IEP or IFSP with application.


Tazewell County Pre-School Partnership

Select Gender
Is your family currently homeless?
Have you applied to another HS or VPI program for 2020 - 2021?
Lives with child?
Lives with child
Does you child have insurance?
Please check all types of insurance that apply
Are your child’s immunizations (shots) up to date?
Does your child have any special needs we should be aware of such as: (please mark all that apply)
Does your child receive special education services or related services (have an IFSP or IEP)?(If yes, staff will need a Release of Information.)
Does your child have any chronic health conditions and/or developmental concerns they have seen a specialist for and/or prescribed medication?
Is child a Foster Child
Education/Training for Parent/Guardian 1(Complete only for parent/guardians living with child)
Education/Training for Parent/Guardian 2(Complete only for parent/guardians living with child)
Work/School for Parent/Guardian 1(Please put checkmark in all boxes that apply for each)
Work/School for Parent/Guardian 2(Please put checkmark in all boxes that apply for each)
Do you receive housing assistance?(i.e. rental assistance, no monthly rent or mortgage payment, HUD or other subsidy)
Need transportation?

Clinch Valley Community Action Head Start and Public Schools program takes into consideration a number of factors in order to determine eligibility. In addition to your income level and the age of your child, members in household, and family needs are noted. The information is voluntary. This information will be considered along with other information shared with our staff during the application process in order to determine eligibility and become familiar with your family. 

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